RADIOLOGICAL ANATOMY

OF SHOULDER JOINT

Dr. Syed Naziya

MD(Anatomy), DMRE
Asst. Prof (Anatomy) & Consultant Radiologist
Deccan collage of medical Sciences,
Hyderabad
Acknowledgements
Dr. Anand Abkari
Prof . Dept of Radiology, DCMS.
Dept of Radiology, DCMS.
Dr. Althaf Ali
 Objectives
Anatomy of Shoulder joint :
Type, Articulating surfaces
Ligaments & Bursae around the joint
Factors maintaining stability of joint
Blood Supply, Nerve Supply & Movements
Muscles of shoulder joint
Applied anatomy :
Shoulder Dislocation
Bursitis
Impingement syndrome
Rotator Cuff Tear
Bicipital tendinitis
Adhesive capsulitis /Frozen shoulder
Introduction
The Shoulder connects the upper limb to the trunk.
Joints of the Shoulder region:
Gleno humeral Joint (The Shoulder Joint)
Acromio clavicular Joint
Sterno clavicular Joint Joints of shoulder girdle
Scapulo thoracic linkage

The shoulder joint has the

greatest range of motion
than any joint in the body..
The Shoulder Joint
Type: Multiaxial Synovial ball-and-socket joint
Only 1/4th part of head of humerus is in contact with
glenoid cavity..
More mobility at the cost of stability
This freedom of movements results from the looseness of
the articular capsule and shallowness of the glenoid
cavity in relation to the large size of the head of humerus.
Although the ligaments of the shoulder strengthen it to
some extent, most of the strength results from the muscle
surround the joint, especially rotator cuff muscles.
So they are called as GUARDIAN OF THE SHOULDER
JOINT.
Articular surfaces
The rounded head of
humerus and shallow, pear-
shaped glenoid cavity of
scapula
Articular surfaces are covered
by hyaline articular
cartilage
Glenoid cavity is deepened by
glenoid labrum
(fibrocartilaginous rim)
Bone Landmarks

Coracoid Process

Subscapular
fossa
Ligaments of shoulder joint
Capsular ligament
Glenoid labrum
Glenohumeral ligament
Coracohumeral ligament
Transverse humeral ligament
Coracoacromial Ligament -
Accessory ligament
It along with coracoid and
acromian forms
coracoacromial arch which
is a secondary socket to
head of humerus during
abduction
Glenohumeral ligament
 Joint capsule
It is thick and strong but very lax.
It attached medially beyond the supraglenoid
tubercle and labrum; laterally to anatomical
neck of humerus and extends inferiorly onto
surgical neck as axillary recess.

Near the humerus it is thickened &

strenthened by fusion of rotator cuff
tendons
Superiorly it is deficient for passage
of biceps long head
Anteriorly it is reinforced by
glenohumeral ligaments
 Applied importance of capsular attachment
Inferior part is weakest - resulting in dislocations
OSTEOMYELITIS of upper end of humerus spreads
directly to joint; due to capsule extension to medial side of
neck
Synovial Membrane
It lines the fibrous capsule.
It 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
 Synovial sleeve glides to & fro
with the tendon of long head of
biceps during adduction abduction
of shoulder joint
The subacromial bursa is partly
covered by acromion process but
during overhead abduction the
bursa is withdrawn beneath the
acromion
Rotator interval
triangular interspace
between the supraspinatus
and subscapularis tendons,
through which passes the
long head of biceps.

Rotator interval tears

tears in the capsule between
the supraspinatus and
subscapularis tendons
Can be classified as
subtype of RTC tears
 Glenoid labrum
It is a fibrocartilagenous rim attached to the margins of glenoid
cavity and increases concavity and suface area of glenoid
cavity.
It further strengthened by long head of biceps origin and
glenohumeral ligament
 Labral variants
These normal variants are all located in the 11-3 o'clock
position.
It is important to recognize these variants, because they can
mimic a SLAP tear.
These normal variants does not mimic a Bankart lesion, since these are
located at the 3-6 o'clock position, where these normal variants do not occur.
 Glenohumeral ligaments
3 bands: best seen from
within the joint cavity
Superior
Middle
Inferior-thickest
provides stability
-especially anteriorly &
inferiorly
Extend from the glenoid
cavity to the lesser tubercle
and anatomical neck of the
humerus
 LIGAMENTS
4. Accessory ligament:
The coracoacromial
ligament
2. Coracohumeral
Ligament.

1. The glenohumeral
ligaments

3. Transverse
humeral ligament
Superiorly-
coracoacromial arch,
Relations of shoulder joint
subacromial bursa, Post Ant

supraspinatus,deltoid
Inferiorly-
long head of triceps
Axillary nerve & Post.
circumflex humeral vessels
Anteriorly-
subscapularis,
coracobrachialis
biceps short head, deltoid [ant fibres]
Posteriorly- infraspinatus, teres minor, deltoid [post fibres]
Within Joint- Long head of biceps
 S
A P
SS

I IS

TM
D
D
Sagittal
Section
Bursae around the shoulder region
Bursa is a sac like cavity filled with synovial fluid.
It provides a cushion between bones and tendons and/or muscles
around a joint & prevent friction.
The joint cavity
communicates with the
subscapular bursa
through an aperture
between superior and
middle band of
glenohumeral ligament
 Anterior circumflex
humeral Artery
Posterior circumflex
humeral Artery
Subscapular Artery
Branches of axillary artery
Suprascapular Artery
Branch of thyrocervical
Blood Supply trunk
 Nerve Supply

Axillary nerve
Suprascapular nerve
Subscapular nerve
Lateral Pectoral Nerve
Principal muscles around shoulder
1. Scapulohumeral muscles
Rotator cuff muscles
Deltoid
Teres major
2. Axioappendicular muscle group
Lattismus dorsi
Pectoralis major
Serratus anterior
trapezius
rhomboids and
Levator scapulae
Rotator Cuff Muscles
Group of muscles that act to
hold the head of the humerus
into the glenoid fossa
Supraspinatus
Infraspinatus
Teres Minor
Subscapularis
ROTATOR
CUFF
 Supraspinatus
Origin supraspinous fossa
of scapula

Insertion Greater tubercle

of humerus (superior aspect)

Action initially abduction

(15 degrees) at shoulder
joint, stabilizing shoulder
joint

Nerve supply - Suprascapular

nerve
Axis of supraspinous tendon
oblique coronal view
 Infraspinatus
Origin Infraspinous fossa of
scapula

Insertion Greater tubercle

of humerus (middle aspect)

Action Laterally rotation

and adduction arm at
shoulder joint

Nerve supply - Suprascapular

nerve
Teres Minor
Origin Inferior lateral border
of scapula

Insertion Greater tubercle of

humerus (posterior inferior
aspect)

Action Laterally rotation,

extends and adduction arm at
shoulder joint

Nerve supply axillary nerve

Subscapularis
Origin subscapular fossa
of scapula

Insertion lesser tubercle of

humerus

Action Medial rotation

arm at shoulder joint

Nerve supply upper and

lower subscapular nerve
 Rotator Cuff Muscles Actions
Supraspinatus: 1st 15-20 degrees of abduction
Infraspinatus: external rotation
Teres minor: external rotation
Subscapularis: internal rotation
 Deltoid
ORIGIN
3 heads:
Ant border lat 1/3rd clavicle
Acromian lateral border
Lower lip crest of spine of scapula

INSERTION
Deltoid tuberosity on humerus

NERVE SUPPL
Axillary nerve[c5,6]

ACTION
Acromial fibres- abductors
Anterior fibres- flexors and medial rotators
Posterior fibres- extensors and lateral rotators
 Teres Major
Origin Inferior angle of
scapula
Insertion medial lip of
Intertubecular sulcus of
humerus
Action
Extends arm at shoulder joint
Assist in adduction and
medial rotation of arm at
shoulder joint.
Nerve supply
Lower subscapular nerve
Coracobrachialis
Origin - Coracoid process of
scapula

Insertion - Middle of medial

surface of shaft of humerus.

Action - Flexion and adduction

arm at shoulder joint.

Nerve supply -
Musculocutaneous nerve
Biceps Brachii
Origin
Short head - Coracoid process of
scapula
Long head - supraglenoid tubercle

Insertion radial tuberosity of

radius and bicipital aponeurosis

Action Flexion forearm at elbow

joint, supination at radioulnar joint
and assist flexion arm at GH joint .

Nerve supply - Musculocutaneous

nerve
Stability of Shoulder Joint
Static stabilizers
glenohumeral ligaments
Video Clip
glenoid labrum and capsule

Dynamic stabilizers
Predominantly rotator cuff muscles and biceps (long head)
Scapular stabilizers :
Trapezius, levator scapulae, serratus anterior, rhomboids.

Rotator cuff muscles counteract the action of the deltoid by

preventing the head of the humerus from moving superiorly
when the arm is raised.
 Shoulder joint injuries
Frequently injured due to anatomical
design
shallowness of glenoid fossa
laxity of ligamentous structures
lack of strength & endurance in
muscles
Lacks bony stability
Common shoulder pathologies
Shoulder Subluxation/Dislocation
AC joint dislocation
Bursitis
Impingement syndrome
Rotator Cuff Tear
Bicipital tendinitis
Adhesive Capsulitis

Radigraphic views for Shoulder joint

 AP : Routine view
AP relative to
thorax
Suboptimal view of
Glenohumeral joint
Good view of AC
joint
AP View : External Rotation

Greater tuberosity & soft tissues profiled and better

visualized
AP View: Internal Rotation

May demonstrate Hill-Sachs lesions

Axillary lateral View

Good view of anterior-posterior relationship of GH joint

Scapular Y Lateral View
Shoulder impingement:
to evaluate the subacromial space
and the supraspinatus outlet
Anterior Dislocation
Posterior Dislocation
Shoulder Subluxation/Dislocation
Dislocation:
Complete separation of articular surfaces
Subluxation:
Abnormal translation of humeral head on glenoid without
complete separation of articular surfaces
Types : Shoulder dislocations are usually divided according to
the direction in which the humeral exits the joint:
anterior : > 95 %
Subcoracoid (most common)
subglenoid (associated with # greater tuberosity, or # glenoid rim)
Subclavicular

Intrathoracic-very rare

posterior : 2 - 4 %
inferior (luxatio erecta) : < 1 %
Anterior dislocation of the shoulder joint

Sudden violence applied to the humerus

with the joint fully abducted and
externally rotated, pushes the humeral
head downward onto the inferior weak
part of the capsule, which tears, and the
humeral head comes to lie
anteroinferiorly
Anterior dislocation

Anterior dislocation
 Anterior dislocation
Once joint capsule and cartilage disrupted Joint is susceptible
to further (recurrent) dislocation
When dislocation occurs, During abduction, the head of
humerus presses against the lower unsupported part of
capsular ligament, Thus, almost always the dislocations
primarily subglenoid, later it may become subcoracoid,
subclavicular or subspinous.
Complications:
Axillary nerve injured (by direct compression of humeral
head on the nerve inferiorly as it passes through quadrangular
space)
Lengthening effect of humerus may stretch the radial nerve
which cause radial nerve paralysis.
Bankart lesion
Avulsion of anteroinferior labrum
(fibrous/bony)
Hill Sachs lesion
Caused by compression of cancellous bone against
anterior glenoid rim creating a divot in the
humeral head
It is a cortical depression in the posterolateral
head of the humerus.
only seen at/above the level of the coracoid

(3-6 position)
LABRUM TEAR
SLAP stands for
"superior labrum, anterior
to posterior"-in other
words, "the top part of the
labrum, from the front to
the back."
Posterior dislocation
Rare
Patients typically present holding their arm
internally rotated and adducted
Most common cause : Extremely vigorous
muscle contraction as in epileptic seizure,
Electric shock or a fall on the flexed and
adducted arm.
Importantly, a posterior dislocation of the
clavicle may impinge on the great vessels
of the superior mediastinum and
compress or disrupt them.
Posterior dislocation AP may appear
normal!
Loss of half moon
elliptical overlap of
humeral head and
glenoid fossa

Rim sign
increased distance
between ant glenoid
rim and articular
surface of humeral
head

Trough sign trough sign

Rim sign Reverse Hill Sachs
(anteromedial
impaction)
 Posterior
dislocation

Light Bulb Sign: due

to internal rotation of
humeral head.
Complications of Post Dislocation
Reverse Bankart lesion
Avulsion of posteroinferior labrum
Reverse Hill Sachs lesion
Caused by compression of cancellous
bone against posterior glenoid rim
creating a divot in the humeral head
Lesser tuberosity fracture
Neurovascular injuries
 Inferior Dislocation
This condition is also called LUXATIO ERECTA because
the arm appears to be permanently held upward or behind
the head. It is caused by a hyper abduction of the arm.
Shoulder tip pain
Irritation of the diaphragm from any surrounding
pathology causes referred pain in the shoulder
This is so because the phrenic nerve and
supraclavicular nerves both arise from spinal segment
C3,C4
Gall bladder disease
Peptic Ulcer Disease
Cervical radiculopathy
Cardiac ischemia
Pulmonary conditions
ie Pancoasts tumor, Pneumonia
Acromicavicular Joint sprain
Occurs due to fall on outstretched arm or tip of
shoulder. May be due to blow to tip of shoulder
Acromioclavicular Dislocation
Common
Shoulder separation
Mechanism:
Fall landing on point or lateral aspect of shoulder
Occasionally from fall on outstretched hand
Rotator cuff tendinitis are
Lesions of the rotator cuff
a common cause of
pain in the shoulder region.
Excessive overhead
activity of the upper limb
may be the cause of
tendinitis
During abduction, the
supraspinatus tendon
undergoes friction against
the acromion.
Under normal conditions
the amount of friction is
reduced to a minimum by
the large subacromial
bursa.
Painful arc Syndrome
 Rotator Cuff Tear
Full or partial thickness disruption
of tendon fibers
Most common in Suprispinatus;
Critical area: 1 cm proximal to the
insertion, due to avascular zone
The patient with a ruptured
supraspinatus tendon is unable to
initiate abduction of the arm.
However, if the arm is passively
assisted for the first 15 of
abduction, the deltoid can then
take over and complete the
movement to a right angle.
 Inflammation of the subacromial /
subdeltoid bursa
bursa may become inflamed, making movements of the
glenohumeral joint painful
Subacromial impingement
Etiology
Subacromial spur, AC Osteoarthritis
Type III (hooked) acromion
Lateral down sloping of anterior acromion
Os acromiale
Acromial Types

Type I
Type II
Type III
 Type IV
Subacromial space < 7 mm: risk of impingement
Os acromiale
Unfused acromial ossification
center
Normally fuses by 25-30 years
Mature bone with
synchondrosis between os and
acromion
+/- mobile distal acromion
Can cause impingement
because if it is unstable, it
may be pulled inferiorly
during abduction by the
deltoid, which attaches here.
Types
Meta-meso (type A)
Basi-meta (type C)
Meso-pre (type B
most common)
 Adhesive Capsulitis/ Frozen shoulder
Thickening & contraction of capsule
The capsule and Connective tissue surrounding the
glenohumeral joint becomes inflamed and stiff, and
develops adhesions, greatly restricting motion and causing
chronic pain

Mechanism: Unknown
Possibly secondary
to pain & guarding of
shoulder
Trauma
rotator cuff tendinitis,
DM
connective tissue disorders
 Nerve Entrapments
Impingement of suprascapular nerve
Location at supraglenoid notch / Spinoglenoid notch
 Quadrilateral space syndrome
Entrapment neuropathy (compression) of axillary nerve
in quadrilateral space
Boundaries
Superiorly teres major
Inferiorly teres minor
Medially long head of
triceps
Laterally humerus
Summary
Shoulder joint -
More mobility at the cost of stability
rotator cuff muscles - guardian of the shoulder joint

Shoulder dislocations and its complication

Rotator cuff tendinitis
Thank you