Lecture 4- Shoulder Complex, Elbow Complex, Wrist and Hand Complex Flashcards
SHOULDER COMPLEX
SHOULDER COMPLEX
What are the 3 bones that make up the shoulder complex?
- clavicle
- scapula
- humerus
What are the 4 joints that contribute to the shoulder complex?
- sternoclavicular (SC)
- acromioclavicular (AC)
- glenohumeral (GH)
- scapulothoracic
What bones make up the SC joint?
Medial clavicle to manubrium (sternum)
What type of joint is the SC joint?
Saddle
What is located at the SC joint to increase congruency?
disc
What are the passive structures providing stabilization to the SC joints and how do they do so?
- Fibrous Joint Capsule-restrain anterior and posterior translation of medial clavicle
- Anterior and Posterior SC ligaments- reinforce capsule by restricting anterior and posterior translation of clavicle
- Costoclavicular ligament (ant and post bundles)-limit elevation of lateral clavicle, contribute to inferior glide of medial clavicle in elevation, shock absorption
- Interclavicular ligament- limits excessive depression and superior glide of clavicle
The SC disc creates 2 joint spaces to promote stability by; increasing joint _________, ________ forces, helps limit ________ movement of clavicle.
- congruency
- absorbing
- medial
What are some muscles that help to stabilize the SC joint?
- SCM
- Sternothyroid
- Sternohyoid
- Subclavius
What are the osteokinematic motions that occur at the SC joint?
- elevation/depression
- protraction/retraction
- anterior/posterior rotation
- In elevation/depression of the SC joint, the disc remains ____________, and we have _______ on _________ structure of the joint.
- During elevation, the lateral clavicle will rotate upward and we will see a ________ roll and a _______ glide.
- During depression, the lateral clavicle will rotate downward and we will see a __________ roll and a __________ glide.
- stationary, convex on concave
- superior roll, inferior glide
- inferior roll, superior glide
- In protraction/retraction of the SC joint, the disc _____ with the clavicle, and we have a _______ on __________ structure of the joint.
- During protraction, the lateral clavicle will move anteriorly and we will see a _______ roll and a ________ glide.
- During retraction, the lateral clavicle will move posteriorly and we will see a ______ roll and a _________ glide.
- moves, concave on convex
- anterior, anterior
- posterior, posterior
- In anterior/posterior rotation of the SC joint, the motion occurs around the clavicles _______ axis.
- During posterior rotation, the inferior surface turns _______.
- During anterior rotation, the inferior surface turn _________ and has ________ motion from neutral.
- longitudinal
- anterior
- back inferior, minimal
What is the closed pack position of the SC joint?
full posterior rotation (full arm elevation)
What is the open pack position of the SC joint?
arm resting at side
What is the capsular pattern at the SC joint?
pain at end range with arm overhead
What bones make up the acromioclavicular joint?
-lateral clavicle to acromion
What type of joint is the AC joint?
plane synovial
The AC joint surfaces are __________, and a disc may or may not be present.
incongruent
What are the passive structures providing stabilization to the AC joints and how do they do so?
- Joint Capsule- weak, requires reinforcement
- Superior AC ligament- restricts anterior clavicular/posterior acromion translation
- Inferior AC ligament, reinforced by deltoid and trapezius
- Coracoclavicular ligament (trapeziod and conoid ligaments)- limits superior clavicular/ inferior scapular translation and posterior rotation of clavicle
- The primary function of the AC joint is to allow the _______ to rotate during arm movement.
- It increases ___ motion, positions the ________ beneath the humeral head, and maintains congruency of the scapula on the ________.
- scapula
- UE, glenoid, thorax
What are the osteokinematic motions that occur at the AC joint?
- internal/external rotation
- anterior/posterior tilting (tipping)
- upward/ downward rotation
Internal/external rotation at the AC joint is important for maintaining contact of the scapula on the curved thorax during _______ and ________ of the clavicle.
-protraction and retraction
Anterior/posterior tilting (tipping) at the AC joint is important for maintaining contact of the scapula on the curved thorax during __________ and _________ of the clavicle.
-elevation and depression
Upward/downward rotation at the AC joint is important for positioning the __________ in the optimal position.
-glenoid fossa
The arthrokinematics for AC joint motions are NOT ________.
defined
What is the closed pack position for the AC joint?
arm at 90 degrees
What is the open pack position for the AC joint?
arm by side
What is the capsular pattern for the AC joint?
pain at end range with arm overhead
- Is injury to the AC joint common in contact sports? Why or why not?
- Development of post-traumatic what may occur after repeated shoulder injuries?
- Yes, it is susceptible to dislocation due to the sloped nature of the articular process coupled with high probability of recieving large shearing forces.
- osteoarthritis
What bones make up the scapulothoracic “joint”?
Is it a true anatomical joint?
- scapula and thorax
- no
The scapulothoracic articulation depends on the integrity of what joints?
SC and AC joints
- What are the primary movements at the scapulothoracic joint?
- What are the secondary movements at the scapulothoracic joint?
Primary -elevation/depression -protraction/retraction -upward/downward rotation Secondary -anterior/posterior tilting, internal/external rotation
- During elevation of the scapulothoracic joint, the SC joint will _______ and the AC joint will ____________.
- During depression of the scapulothoracic joint, the SC joint will _______ and the AC joint will __________.
- elevate, downwardly rotate
- depress, upwardly rotate
- During protraction of the scapulothoracic joint, the SC joint will ________ and the AC joint will __________.
- During retraction of the scapulothoracic joint, the SC joint will _______ and the AC joint will __________.
- protract, internally rotate
- retract, externally rotate
- During upward rotation of the scapulothoracic joint, the SC joint will _________ and the AC joint will _______.
- During downward rotation of the scapulothoracic joint, the SC joint will _________ and the AC joint will _______.
- elevation, upward rotation
- depression, downward rotation
What bones make up the glenohumeral joint?
glenoid fossa and head of the humerus
What type of joint is the GH joint?
ball and socket
- What is the angle of inclination of the GH joint?
- What is the angle of torsion of the GH joint?
- What is retroversion of the GH joint?
- 130 to 150 degrees in the frontal flane
- 30 degrees posterior in the transverse plane
- posterior orientation of humeral head with regard to the condyles to keep the articulating surfaces more congruent
Pitchers will have ________ retroversion, which will result in higher ____ and reduced _____
- increased
- ER, IR
What are the passive structures providing stabilization to the GH joint and how do they do so?
- Glenoid Labrum- enhances concavity and increases articular surface; resists humeral head translation, dissipates forces, protects bony edges; attachment of GH ligaments and tendon of biceps long head
- Joint Capsule- significant laxity, minimal stability provided; reinforced by thicker external ligaments; inferior portion is slack in adducted position creating axillary pouch
There is a relationship between tight posterior capsule and ______________________.
-shoulder impingement
Tightness in the posterior shoulder capsule may produce increased anterior humeral head translation, which in turn decreases the ______________ space.
-subacromial
What are the 4 ligaments of the GH joint?
- superior glenohumeral lig.
- middle glenohumeral lig.
- inferior glenohumeral lig.
- coracohumeral lig.
The superior GH ligament will limit ________ rotation and ________/__________ translation at 0 degrees abduction. The ligament will also _______ when abducted beyond 35-45 degrees.
- external
- anterior/inferior
- slacken
The middle GH ligament will limit ________ translation from 45-90 degrees of abduction and extremes of ____________ rotation.
- anterior
- external
- The inferior GH ligament is composed of what 3 parts?
- The __________ GH ligament is the primary stabilizer beyond 45 degrees of abduction or with combined abduction and rotation.
- anterior band, posterior band, axillary pouch
- inferior
The coracohumeral ligament limits _________ translation and ________ rotation of the humeral head with the arm hanging at the side.
- inferior
- external
- The rotator cuff reinforces the ___ joint capsule.
- What are the 2 areas where the rotator cuff does not reinforce?
- GH
- inferiorly, region between subscapularis and supraspinatus (rotator cuff interval)
What structures help to reinforce the rotator cuff interval?
- long head of biceps
- coracohumeral ligament
- superior and middle GH ligaments
What are the osteokinematic motions that occur at the GH joint?
- flexion/extension
- ab/adduction
- internal/external rotation
- During flexion of the GH joint, we will have a _______ roll and a ________ glide.
- During extension of the GH joint, we will have a _________ roll and a __________ glide.
- anterior, posterior
- posterior, anterior
- During adduction of the GH joint, we will have a __________ roll and a _______ glide.
- During abduction of the GH joint, we will have a __________ roll and a _______ glide.
- inferior, superior
- superior, inferior
What must occur to perform full abduction at the GH joint?
external rotation
What ligament tightens with abduction?
inferior GH
- During external rotation of the GH joint, we will have a ________ roll and a _______ glide.
- During internal rotation of the GH joint, we will have a _______ roll and a _______ glide.
- posterior, anterior
- anterior, posterior
What is the closed pack position of the GH joint?
90 degrees abducted and full external rotation or full abduction and external rotation
What is the open pack position of the GH joint?
abducted 55 degrees, then horizontally adducted 30 degrees, slight ER
What is the capsular pattern of the GH joint?
ER>Abduction>IR
In regards to the scapulohumeral rhythm, ___ degrees of abduction comes from the GH joint, while the other ___ degrees comes from the scapulothoracic upward rotation.
- 120
- 60
What is the ideal shoulder girdle posture?
- slightly elevated and relatively retracted scapula
- results in glenoid fossa facing slightly upward
What are the effects of gravity on scapulothoracic posture?
results in depressed, protracted, and excessively downwardly rotated scapula
Describe the impact of rounded shoulders on an individual’s shoulder complex.
- slight depression, downward rotation, and protraction of scapula
- predisposes individual to shoulder impingement
How do the rhomboids and lower trap function together?
- lower trap pulls down and in, rhomboid pulls up and in, resulting in pure retraction
- act as a force couple
How do the deltoids and supraspinatus function together?
- both act to perform abduction
- supraspinatus can typically perform full abduction in cases of deltoid paralysis, but the torque is reduced
- full abduction is difficult but achievable in cases of supraspinatus paralysis
What is the force couple for upward rotation of the scapula?
-serratus anterior, upper trap, and lower trap are all pulling in different directions to elicit the movement of upward rotation
What is the force couple that causes posterior tilting at the scapula?
serratus anterior pulls anteriorly, lower trap pulls posterior
Whata is the force couple that causes external rotation at the scapula?
serratus anterior pulls anterior portion around, mid trap pulls posterior portion towards spine
Scapular winging is defined as having excessive amount of ____ of the scapula that is visualized with attempted elevation of the arm
-IR
Rotator Cuff and Arthrokinematics:
- Supraspinatus drives the ________ roll of the humeral head, compresses humeral head against glenoid fossa, and creates a spacer above humeral head restricting excessive _________ translation of the humerus.
- The infraspinatus, teres minor, and subscapularis exert a ________ force on the humeral head.
- The infraspinatus and teres minor _________ rotate the humerus during arm motions
- superior, superior
- depression
- externally
How do the infraspinatus and mid trap function together?
- middle trap acts to stabilize the scapula while the infraspinatus externally rotates the shoulder
- if the middle trap was paralyzed, the scapula would move into internal rotation as the GH joint is ER which creates scapular dyskinesis
What is scapular dyskinesis?
any abnormal position or movement of the scapula
ELBOW COMPLEX
ELBOW COMPLEX
What are the joints of the elbow complex?
- elbow (humeroulnar and humeroradial)
- proximal and distal radioulnar
What bones make up the humeroulnar and humeroradial joints?
What type of joints are they?
- Humeroulnar- trochlear notch of ulna to trochlea of the humerus
- Humeroradial- head of the radius to the capitulum of the humerus
-Modified hinge
The elbow and proximal radioulnar joint are enclosed in a ________ joint capsule. The capsule is large, loose, and weak _______ and _________. The elbow joint is reinforced laterally by ________ ligaments.
- single
- anterior and posterior
- collateral
What is the carrying angle and what is the normal range?
- angle between the humerus and forearm
- 8-15 degrees
Valgus=
Varus=
Valgus= increased carrying angle -Varus= decreased carrying angle
What is the purpose of the carrying angle?
allows for a person to carry onjects away from the side of the thigh
The medial (ulnar) collateral ligament stabilizes against ______ torque.
valgus
The lateral (radial) collateral ligament stabilizes against ______ torque.
varus
What are the osteokinematic motions that occur at the humeroulnar joint?
flexion/extension
Is the humeroulnar joint convex on concave or concave on convex?
concave on convex
- During flexion of the humeroulnar joint, we see an __________ roll and a _________ glide.
- During extension of the humeroulnar joint, we see an _________ roll and a ________ glide.
- anterior, anterior
- posterior, posterior
Is the humeroradial joint convex on concave or concave on convex?
concave on convex
- During flexion of the humeroradial joint, we see an __________ roll and a _________ glide.
- During extension of the humeroradial joint, we see an _________ roll and a ________ glide.
- anterior,anterior
- posterior, posterior
What is the closed pack position for the humeroulnar and humeroradial joint?
- Humeroulnar- full extension and supination
- Humeroradial- 90 degrees elbow flexion and 5 degrees supination
What is the open pack position for the humeroulnar and humeroradial joint?
- Humeroulnar- flexed 70 degrees and supinated 10 degrees
- Humeroradial- full extension and supination
What is the flexion/extension ROM at the elbow joint?
Flexion= 150 degrees Extension= 0 degrees
What is the capsular pattern for the elbow joint?
Flexion>extension
What bones make up the proximal and distal radioulnar joints?
What type of joints are they?
- Proximal- ulnar radial notch to head of radius
- Distal- ulnar notch of radius to head of ulna
-Pivot joint type
- Is the proximal radioulnar joint convex on concave or concave on convex?
- Is the distal radioulnar joint convex on concave or concave on convex?
- convex on concave
- concave on convex
What are the osteokinematic motions that occur at the proximal radioulnar joint?
supination/pronation
- During supination of the proximal radioulnar joint, we see a ___________ rotation/spin and a ___________ glide.
- During pronation of the proximal radioulnar joint, we see a _________ rotation/spin and a _________ glide.
- posterior, anterior
- anterior, posterior
What are the osteokinematic motions that occur at the distal radioulnar joint?
supination/pronation
- During supination of the distal radioulnar joint, we see a ___________ rotation/spin and a ___________ glide.
- During pronation of the distal radioulnar joint, we see a _________ rotation/spin and a _________ glide.
- posterior, posterior
- anterior, anterior
What is the closed pack position for the proximal and distal radioulnar joints?
- 5 degrees of supination
- 5 degrees of supination
What is the open pack position for the proximal and distal radioulnar joints?
- 70 degrees of elbow flexion and 35 degrees of supination
- 10 degrees of supination
What is the ROM of supination/pronation?
80 degrees supination
80 degrees pronation
What is the capsular pattern for the proximal and distal radioulnar joints?
supination=pronation
Flexor torque is 20-25% greater with the elbow in a ________ position compared to __________ position.
- supinated
- pronated
What muscle is considered the workhorse of the elbow and can produce equal force regardless of supination and pronation?
brachialis
Describe the synergy between the triceps and anterior deltoid.
In a pushing motion, our anterior delt will perform shoulder flexion to counteract the shoulder extension performed by the triceps.
Which muscle is primarily activated during low level supination?
supinator
Which 2 muscles are primarily activated to produce forceful supination?
supinator and biceps brachii
What role does the tricep play during forceful supination?
prevents biceps from flexing the elbow and shoulder during supination
Which muscle is primarily activated during low level pronation?
pronator quadratus
Which 2 muscles are primarily activated to produce forceful pronation?
- pronator quadratus
- pronator teres
WRIST AND HAND COMPLEX
WRIST AND HAND COMPLEX
What joints make up the wrist and hand complex?
-distal radioulnar
-wrist complex (radiocapral and midcarpal)
-carpometacarpal
-metacarpophalangeal
interphalangeal
What are the 2 points of consensus in regards to the wrist complex?
- structure and biomechanics of wrist and hand vary tremendously from person to person
- even subtle variations can produce differences in the way a given function occurs
What are the bones of the radiocarpal joint and midcarpal joint?
Radiocarpal
-radius with scaphoid, lunate, and triquetrium
Midcarpal
-scaphoid, lunate, and triquetrium with trapezium, trapezoid, capitate, and hamate
What type of joints are the radiocarpal and midcarpal joints?
biaxial condyloid
What is the benefit of having a 2 joint system (radiocarpal and midcarpal joints)?
- permits large ROM with less exposed articular surface and tighter joint capsules
- less tendency for structural pinch at extremes of motion
- allows for flatter multi-joint surfaces that are more capable of withstanding imposed pressures
The proximal component of the radiocarpal joint is the _______ surface of the radius. The distal components of the radiocarpal joint are the _______ surfaces of the scaphoid, lunate, and triquetrium.
- concave
- convex
The ligaments of the wrist are small and difficult to isolate but they are essential for what?
- maintaining intercarpal alignment
- transferring forces within and across carpals
The wrist ligaments are described as extrinsic and intrinsic, what is the difference?
- extrinsic- have a proximal attachment on the forearm
- intrinsic- have both proximal and distal attachments within the wrist complex
What is the triangular fibrocartilage complex (TFCC)?
- functions to bind distal ends of radius and ulna while allowing radius to rotate around the fixed ulna
- reinforces ulnar side of wrist and allows transfer of compression forces
What is the function of the extensor retinaculum?
prevents “bowstringing” of tendons with movement of wrist
What is located beneath the extensor retinaculum?
6 compartments that house specific set of tendons
Repetition of forceful activities may cause tenosynovitis to occur, what is this?
inflammation within compartments under the extensor retinaculum
What is the function of the palmar carpal ligament?
stabilizes wrist flexor tendons to prevent excessive “bowstringing” during wrist flexion
What two wrist structures prevent bowstringing?
- extensor retinaculum
- palmar carpal ligament
_ extrinsic flexor tendons and the ______ nerve pass through the carpal tunnel
- 9
- median
What is the most frequent UE nerve entrapment?
What factors can result in this?
- carpal tunnel syndrome (CTS)
- overcrowding, excessive mechanical stress, fibrotic changes of connective tissue (transverse carpal ligament)
What are the osteokinematic motions that occur at the wrist joint (radiocarpal and midcarpal)?
- flexion/extension
- radial/ulnar deviation
Is the wrist joint concave on convex or convex on concave?
convex on concave
- During flexion of the wrist joint, we see a ________ roll and a _________ glide.
- During extension of the wrist, we see a ________ roll and a _______ glide.
- anterior, posterior
- posterior, anterior
During radial deviation of the wrist joint, we see a _______ roll and a _______ glide.
During ulnar deviation of the wrist joint, we see a _________ roll and a ______ glide.
- lateral, medial
- medial, lateral
What is the closed pack position for the wrist joint?
full extension with radial deviation
What is the open pack position for the wrist joint?
neutral flexion/extension with slight ulnar deviation
What is the ROM for wrist flexion, extension, radial deviation, ulnar deviation?
- flexion-80
- extension-70
- radial deviation-20
- ulnar deviation-30
What is the capsular pattern for the wrist joint?
flexion=extension, slight radial and ulnar deviation
What are the primary and secondary wrist extensors?
Primary -extensor carpi radialis longus -extensor carpi radialis brevis -extensor carpi ulnaris Secondary -extensor digitorum -extensor indicis -extensor digiti minimi -extensor pollicis longus
What are the primary and secondary wrist flexors?
Primary -flexor carpi radialis -flexor carpi ulnaris -palmaris longus Secondary -flexor digitorum profundus -flexor digitorum superficialis -flexor pollicis longus -abductor pollicis longus -extensor pollicis brevis
What is the main function of wrist extensors?
- position and stabilize wrist with activities that require active flexion of the digits (making a fist)
- counterbalance wrist flexion torque produced by finger flexor muscles
What degrees provides the max grip?
30 degrees of extension
The FCU and FCR act synergistically to oppose ____________ during wrist flexion.
radial and ulnar deviation
What are the joints of the hand?
- carpometacarpal (CMC)
- metacarpophalangeal (MCP)
- 2 interphalangeal (PIP and DIP)
What are the bones of the CMC joint?
- 1st through 5th metacarpals
- trapezium, trapezoid, capitate, hamate
What type of joints are the CMC joints?
- 1st digit is saddle
- 2nd-5th are planar
What are the passive structures supporting the 1st CMC joint?
- anterior oblique
- first intermetacarpal
- posterior oblique
- ulnar collateral
- radial collateral
What are the passive structures supporting the 2nd-5th CMC joints?
- dorsal carpometacarpal
- palmar carpometacarpal
- dorsal intermetacarpal
- palmar intermetacarpal
What are the osteokinematic motions occuring at the 1st CMC joint?
- flexion/extension
- abduction/adduction
- opposition/reposition
Is the 1st CMC joint convex on concave or concave on convex?
depends on the movement
- During abduction of the 1st CMC joint, we will see a ________ roll and a ________ glide.
- During adduction of the 1st CMC joint, we will see a __________ roll and a ________ glide.
- anterior, posterior
- posterior, anterior
- During flexion of the 1st CMC joint, we will see a ________ roll and a ________ glide.
- During extension of the 1st CMC joint, we will see a __________ roll and a ________ glide.
- medial, medial
- lateral, lateral
- During opposition of the 1st CMC joint, we will see _________ and __________.
- During reposition of the 1st CMC joint, we will see ___________ and __________.
- abduction, flexion
- adduction, extension
The arthrokinematics of the 2nd-5th CMC joints are __________.
undefined
What is the closed pack position for the 1st CMC joint and the 2nd-5th CMC joints?
- 1st CMC- full opposition
- 2nd-5th- full flexion
What is the open pack position for the 1st CMC joint and the 2nd-5th CMC joints?
- 1st CMC- mid flexion/extension and mid ab/adduction
- 2nd-5th- mid flexion/extension
What are the ROM norms for the 1st CMC joint motions? Flexion Extension Abduction Adduction
Flexion-15
Extension-35
Abduction-70
Adduction-0
What is the capsular pattern for the 1st CMC joint?
abduction
What are the bones that make up the MCP joint?
metacarpal with proximal phalanx
What type of joint is the MCP joint?
condyloid
What are the osteokinematic motions that occur at the MCP joints?
- flexion/extension
- abduction/adduction
Are the MCP joints concave on convex or convex on concave?
concave on convex
- During flexion of the MCP joints, we will see a ________ roll and a ________ glide.
- During extension of the MCP joints, we will see a _______ roll and a ________ glide.
- anterior, anterior
- posterior, posterior
- During abduction of the MCP joints, we will see a roll and glide _____ from the 3rd digit.
- During adduction of the MCP joints, we will see a roll and glide ________ the 3rd digit.
- away
- toward
What is the closed pack position of the MCP joints?
full flexion
What is the open pack position of the MCP joints?
slight flexion
What are the ROM norms at the MCP joints?
Flexion
Extension
Ab/adduction
- Flexion- 90
- Extension- 45
- Ab/adduction- 0-20
What is the capsular pattern of the MCP joints?
flexion=extension
What are the bones involved at the IP joints?
proximal, middle, and distal phalanges
What type of joint are the IP joints?
hinge
What are the osteokinematic motions that occur at the IP joints?
flexion/extesion
Are the IP joints concave on convex or convex on concave?
concave on convex
- During flexion of the IP joints, we will see a _______ roll and a _______ glide.
- During extension of the IP joints, we will see a _______ roll and a ______ glide.
- anterior (palmar), anterior
- posterior (dorsal), posterior
What is the closed pack position of the IP joints?
full extension
What is the open pack position of the IP joints?
slight flexion
What are the ROM norms at the IP joints?
flexion- 100
extension- 0
What is the capsular pattern of the IP joints?
flexion=extension
What is the function of the flexor mechanism?
function to prevent bowstringing of the tendons with contraction of finger flexors
Trigger finger occurs secondary to __________.
tenosynovitis
What is the structure of the extensor mechanism?
- tendon of extensor digitorum attaches to dorsal side of proximal phalanx
- remaining tendon flattens into a central band
- central band divides into 2 lateral bands before crossing the PIP joint
- bands reconverge distally