6c. Humeral Articulation or Shoulder-joint

(Articulatio Humeri) (Fig. 326)

The shoulder-joint is an enarthrodial or ball-and-socket joint. The bones entering into its formation are the hemispherical head of the humerus and the shallow glenoid cavity of the scapula, an arrangement which permits of very considerable movement, while the joint itself is protected against displacement by the tendons which surround it. The ligaments do not maintain the joint surfaces in apposition, because when they alone remain the humerus can be separated to a considerable extent from the glenoid cavity; their use, therefore, is to limit the amount of movement. The joint is protected above by an arch, formed by the coracoid process, the acromion, and the coracoacromial ligament. The articular cartilage on the head of the humerus is thicker at the center than at the circumference, the reverse being the case with the articular cartilage of the glenoid cavity. The ligaments of the shoulder are: 1

The Articular Capsule.		The Glenohumeral.
The Coracohumeral.		The Transverse Humeral.
The Glenoidal Labrum. 70

The Articular Capsule (capsula articularis; capsular ligament) (Fig. 327).—The articular capsule completely encircles the joint, being attached, above, to the circumference of the glenoid cavity beyond the glenoidal labrum; below, to the anatomical neck of the humerus, approaching nearer to the articular cartilage above than in the rest of its extent. It is thicker above and below than elsewhere, and is so remarkably loose and lax, that it has no action in keeping the bones in contact, but allows them to be separated from each other more than 2.5 cm., an evident provision for that extreme freedom of movement which is peculiar to this articulation. It is strengthened, above, by the Supraspinatus; below, by the long head of the Triceps brachii; behind, by the tendons of the Infraspinatus and Teres minor; and in front, by the tendon of the Subscapularis. There are usually three openings in the capsule. One anteriorly, below the coracoid process, establishes a communication between the joint and a bursa beneath the tendon of the Subscapularis. The second, which is not constant, is at the posterior part, where an opening sometimes exists between the joint and a bursal sac under the tendon of the Infraspinatus. The third is between the tubercles of the humerus, for the passage of the long tendon of the Biceps brachii. 2 The Coracohumeral Ligament (ligamentum coracohumerale).—This ligament is a broad band which strengthens the upper part of the capsule. It arises from the lateral border of the coracoid process, and passes obliquely downward and lateralward to the front of the greater tubercle of the humerus, blending with the tendon of the Supraspinatus. This ligament is intimately united to the capsule by its hinder and lower border; but its anterior and upper border presents a free edge, which overlaps the capsule. 3

FIG. 327– Capsule of shoulder-joint (distended). Anterior aspect. (See enlarged image) Glenohumeral Ligaments.—In addition to the coracohumeral ligament, three supplemental bands, which are named the glenohumeral ligaments, strengthen the capsule. These may be best seen by opening the capsule at the back of the joint and removing the head of the humerus. One on the medial side of the joint passes from the medial edge of the glenoid cavity to the lower part of the lesser tubercle of the humerus. A second at the lower part of the joint extends from the under edge of the glenoid cavity to the under part of the anatomical neck of the humerus. A third at the upper part of the joint is fixed above to the apex of the glenoid cavity close to the root of the coracoid process, and passing downward along the medial edge of the tendon of the Biceps brachii, is attached below to a small depression above the lesser tubercle of the humerus. In addition to these, the capsule is strengthened in front by two bands derived from the tendons of the Pectoralis major and Teres major respectively. 4 The Transverse Humeral Ligament (Fig. 327) is a broad band passing from the lesser to the greater tubercle of the humerus, and always limited to that portion of the bone which lies above the epiphysial line. It converts the intertubercular groove into a canal, and is the homologue of the strong process of bone which connects the summits of the two tubercles in the musk ox. 5 The Glenoidal Labrum (labrium glenoidale; glenoid ligament) is a fibrocartilaginous rim attached around the margin of the glenoid cavity. It is triangular on section, the base being fixed to the circumference of the cavity, while the free edge is thin and sharp. It is continuous above with the tendon of the long head of the Biceps brachii, which gives off two fasciculi to blend with the fibrous tissue of the labrum. It deepens the articular cavity, and protects the edges of the bone. 6 Synovial Membrane.—The synovial membrane is reflected from the margin of the glenoid cavity over the labrum; it is then reflected over the inner surface of the capsule, and covers the lower part and sides of the anatomical neck of the humerus as far as the articular cartilage on the head of the bone. The tendon of the long head of the Biceps brachii passes through the capsule and is enclosed in a tubular sheath of synovial membrane, which is reflected upon it from the summit of the glenoid cavity and is continued around the tendon into the intertubercular groove as far as the surgical neck of the humerus (Fig. 327). The tendon thus traverses the articulation, but it is not contained within the synovial cavity. 7

FIG. 328– Glenoid fossa of right side. (See enlarged image) Bursæ.—The bursæ in the neighborhood of the shoulder-joint are the following: (1) A constant bursa is situated between the tendon of the Subscapularis muscle and the capsule; it communicates with the synovial cavity through an opening in the front of the capsule; (2) a bursa which occasionally communicates with the joint is sometimes found between the tendon of the Infraspinatus and the capsule; (3) a large bursa exists between the under surface of the Deltoideus and the capsule, but does not communicate with the joint; this bursa is prolonged under the acromion and coraco-acromial ligament, and intervenes between these structures and the capsule; (4) a large bursa is situated on the summit of the acromion; (5) a bursa is frequently found between the coracoid process and the capsule; (6) a bursa exists beneath the Coracobrachialis; (7) one lies between the Teres major and the long head of the Triceps brachii; (8) one is placed in front of, and another behind, the tendon of the Latissimus dorsi. 8 The muscles in relation with the joint are, above, the Supraspinatus; below, the long head of the Triceps brachii; in front, the Subscapularis; behind, the Infraspinatus and Teres minor; within, the tendon of the long head of the Biceps brachii. The Deltoideus covers the articulation in front, behind, and laterally. 9 The arteries supplying the joint are articular branches of the anterior and posterior humeral circumflex, and transverse scapular. 10

The nerves are derived from the axillary and suprascapular. 11 Movements.—The shoulder-joint is capable of every variety of movement, flexion, extension, abduction, adduction, circumduction, and rotation. The humerus is flexed (drawn forward) by the Pectoralis major, anterior fibers of the Deltoideus, Coracobrachialis, and when the forearm is flexed, by the Biceps brachii; extended (drawn backward) by the Latissimus dorsi, Teres major, posterior fibers of the Deltoideus, and, when the forearm is extended, by the Triceps brachii; it is abducted by the Deltoideus and Supraspinatus; it is adducted by the Subscapularis, Pectoralis major, Latissimus dorsi, and Teres major, and by the weight of the limb; it is rotated outward by the Infraspinatus and Teres minor; and it is rotated inward by the Subscapularis, Latissimus dorsi, Teres major, Pectoralis major, and the anterior fibers of the Deltoideus. 12 The most striking peculiarities in this joint are: (1) The large size of the head of the humerus in comparison with the depth of the glenoid cavity, even when this latter is supplemented by the glenoidal labrum. (2) The looseness of the capsule of the joint. (3) The intimate connection of the capsule with the muscles attached to the head of the humerus. (4) The peculiar relation of the tendon of the long head of the Biceps brachii to the joint. 13 It is in consequence of the relative sizes of the two articular surfaces, and the looseness of the articular capsule, that the joint enjoys such free movement in all directions. When these movements of the arm are arrested in the shoulder-joint by the contact of the bony surfaces, and by the tension of the fibers of the capsule, together with that of the muscles acting as accessory ligaments, the arm can be carried considerably farther by the movements of the scapula, involving, of course, motion at the acromio- and sternoclavicular joints. These joints are therefore to be regarded as accessory structures to the shoulder-joint (see pages 314 and 316). The extent of the scapular movements is very considerable, especially in extreme elevation of the arm, a movement best accomplished when the arm is thrown somewhat forward and outward, because the margin of the head of the humerus is by no means a true circle; its greatest diameter is from the intertubercular groove, downward, medialward, and backward, and the greatest elevation of the arm can be obtained by rolling its articular surface in the direction of this measurement. The great width of the central portion of the humeral head also allows of very free horizontal movement when the arm is raised to a right angle, in which movement the arch formed by the acromion, the coracoid process and the coracoacromial ligament, constitutes a sort of supplemental articular cavity for the head of the bone. 14 The looseness of the capsule is so great that the arm will fall about 2.5 cm. from the scapula when the muscles are dissected from the capsule, and an opening made in it to counteract the atmospheric pressure. The movements of the joint, therefore, are not regulated by the capsule so much as by the surrounding muscles and by the pressure of the atmosphere, an arrangement which “renders the movements of the joint much more easy than they would otherwise have been, and permits a swinging, pendulum-like vibration of the limb when the muscles are at rest” (Humphry). The fact, also, that in all ordinary positions of the joint the capsule is not put on the stretch, enables the arm to move freely in all directions. Extreme movements are checked by the tension of appropriate portions of the capsule, as well as by the interlooking of the bones. Thus it is said that “abduction is checked by the contact of the great tuberosity with the upper edge of the glenoid cavity; adduction by the tension of the coracohumeral ligament” (Beaunis et Bouchard). Cleland 71 maintains that the limitations of movement at the shoulder-joint are due to the structure of the joint itself, the glenoidal labrum fitting, in different positions of the elevated arm, into the anatomical neck of the humerus. 15 The scapula is capable of being moved upward and downward, forward and backward, or, by a combination of these movements, circumducted on the wall of the chest. The muscles which raise the scapula are the upper fibers of the Trapezius, the Levator scapulæ, and the Rhomboidei; those which depress it are the lower fibers of the Trapezius, the Pectoralis minor, and, through the elavicle, the Subclavius. The scapula is drawn backward by the Rhomboidei and the middle and lower fibers of the Trapezius, and forward by the Serratus anterior and Pectoralis minor, assisted, when the arm is fixed, by the Pectoralis major. The mobility of the scapula is very considerable, and greatly assists the movements of the arm at the shoulder-joint. Thus, in raising the arm from the side, the Deltoideus and Supraspinatus can only lift it to a right angle with the trunk, the further elevation of the limb being effected by the Trapezius and Serratus anterior moving the scapula on the wall of the chest. This mobility is of special importance in ankylosis of the shoulder-joint, the movements of this bone compensating to a very great extent for the immobility of the joint. 16 Cathcart 72 has pointed out that in abducting the arm and raising it above the head, the scapula rotates throughout the whole movement with the exception of a short space at the beginning and at the end; that the humerus moves on the scapula not only while passing from the hanging to the horizontal position, but also in travelling upward as it approaches the vertical above; that the clavicle moves not only during the second half of the movement but in the first as well, though to a less extent—i. e., the scapula and clavicle are concerned in the first stage as well as in the second; and that the humerus is partly involved in the second as well as chiefly in the first. 17 The intimate union of the tendons of the Supraspinatus, Infraspinatus, Teres minor and Subscapularis with the capsule, converts these muscles into elastic and spontaneously acting ligaments of the joint. 18 The peculiar relations of the tendon of the long head of the Biceps branchii to the shoulder-joint appear to subserve various purposes. In the first place, by its connection with both the shoulder and elbow the muscle harmonizes the action of the two joints, and acts as an elastic ligament in all positions, in the manner previously discussed (see page 287). It strengthens the upper part of the articular cavity, and prevents the head of the humerus from being pressed up against the acromion, when the Deltoideus contracts; it thus fixes the head of the humerus as the center of motion in the glenoid cavity. By its passage along the intertubercular groove it assists in steadying the head of the humerus in the various movements of the arm. When the arm is raised from the side it assists the Supraspinatus and Infraspinatus in rotating the head of the humerus in the glenoid cavity. It also holds the head of the bone firmly in contact with the glenoid cavity, and prevents its slipping over its lower edge, or being displaced by the action of the Latissimus dorsi and Pectoralis major, as in climbing and many other movements. 19

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