The Back and Scapular region
Dr Mukesh Singla
Muscles Connecting the Upper
Limb to the Vertebral Column
Movements of Scapula
Movements of Scapula
Movements of Scapula
Movements of Scapula
Arranged in two layers
Layer 1st
a. Trapezus
b. Latissimus dorsi
Layer 2nd
c. Levator scapulae
d. Rhomboideus major
and minor
Trapezius
Origin
• Occipital bone(external occiptal
protuberunce), superior nuchal
line, ligamentum nuchae, spine of
seventh cervical vertebra, spines
of all thoracic vertebrae and their
supraspinous ligament
Insertion
• Upper fibers into posterior
border of lateral third of clavicle
• middle fibres- medial border of
acromion and upper lip of crest of
spine
• lower fibers pass upward and
laterally and insert on medial end
of spine of scapula
Trapezius
Nerve Supply
• Spinal part of accessory nerve
(motor) and ventral rami of C3
and 4 (sensory- proprioceptive)
Action
• Upper fibers along with levator
scapulae elevate the scapula;
• middle fibers with rhomboids
pull scapula medially (retracts);
• lower fibers pull medial border
of scapula downward , so upper
and lower fibres acting together
rotate scapula-glenoid cavity face
upward assisted by lower 5
digitations of serratus anterior
Latissimus dorsi
Origin
• Iliac crest, lumbar fascia, spines of
lower six thoracic vertebrae(T7-
T12), lower three or four ribs, and
inferior angle of scapula (5)
Insertion
• Floor of bicipital groove of
humerus (1)
Nerve Supply
• Thoracodorsal nerve
• C6, 7, 8,
Action
• Extends, adducts, and medially
rotates the arm (3)
• Its called the climbing muscle
• Raising of the trunk above the arm
Levator scapulae
Origin
• Transverse processes of first fourth cervical
vertebrae (1)
Insertion
• Medial border of scapula (1)
Nerve supply
• C3 and 4 and dorsal scapular nerve
• C3, 4, 5
Action
• Raises medial border of scapula
ligamentum nuchae
The ligamentum nuchae is
a large median ligament
composed of tendons and
fascia located between the
posterior muscles of the
neck. It covers the spines of
C1 to C6 vertebrae. It is a
superior and posterior
extension of the
supraspinous ligamen
Rhomboid minor
Origin
• Ligamentum nuchae and
spines of seventh cervical
and first thoracic vertebrae
(3)
Insertion
• Medial border of scapula
(1)
Nerve supply
• Dorsal scapular nerve C4, 5
Rhomboid major
Origin
• Second to fifth thoracic spines
Insertion
• Medial border of scapula (1)
Nerve supply
• Dorsal scapular nerve C4, 5
Action
• Retract scapula
• The rhomboids work collectively with the
levator scapulae muscles to elevate the
medial border of the scapula, downwardly
rotating the scapula with respect to the
glenohumeral joint.
Muscles Connecting the Scapula
to the Humerus
Deltoid
Origin
• Lateral third of clavicle, acromion, spine of
scapula
Insertion
• Middle of lateral surface of shaft of humerus
Nerve supply
• Axillary nerve C5, 6
Action
• Middle fibers Abducts arm; anterior fibers
flex and medially rotate arm; posterior fibers
extend and laterally rotate arm
• Abduction from 15-90 degrees
Intramuscular Injection
Structures under cover of Deltoid
BONE- Upper part humerus, coracoid process
,greater tubercle, lesser tubercle Intertuberculus
sulcus
Bursa- Subdeltoid , subacromial bursa
Muscles – attached around shoulder joint
Vessel- Ant and Post circumflex humeral vessel
Nerves- Axillary
Supraspinatus
Origin
• Supraspinous fossa of scapula
Insertion
• Greater tuberosity of
humerus; capsule of shoulder
joint
Nerve supply
• Suprascapular nerve 5, 6
Action
• Abducts arm and stabilizes
shoulder joint
• Initiation of abduction 0-15
degrees
Infraspinatus
Origin
• Infraspinous fossa of scapula
Insertion
• Middle impression of greater
tubercle of humerus; capsule
of shoulder joint
Nerve supply
• Suprascapular nerve after
passing through spino-glenoid
notch 5, 6
Action
• Laterally rotates arm and
stabilizes shoulder joint
Teres major
Origin
• Lower third of lateral border of scapula
Insertion
• Medial lip of bicipital groove of
humerus
Nerve supply
• Lower subscapular nerve C6, 7
Action
• Medially rotates and adducts arm and
stabilizes shoulder joint
Teres minor
Origin
• Upper two thirds of lateral border
of scapula
Insertion
• Greater tuberosity of humerus;
capsule of shoulder joint
Nerve supply
• Axillary nerve (C4), C5, 6
Action
• Laterally rotates arm and stabilizes
shoulder joint
Subscapularis
Origin
• Subscapular fossa
Insertion
• Lesser tuberosity of humerus
Nerve supply
• Upper and lower subscapular nerves
C5, 6, 7
Action
• Medially rotates arm and stabilizes
shoulder joint
Rotator Cuff
• The rotator cuff is the name
given to the tendons of the
subscapularis, supraspinatus,
infraspinatus, and teres minor
muscles
• are fused to the underlying
capsule of the shoulder joint
• stabilizing the shoulder joint
• The cuff is deficient inferiorly,
and this is a site of potential
weakness.
Rotator Cuff
Axillary Nerve
• The axillary nerve arises from the
posterior cord of the brachial plexus
(C5 and 6) in the axilla
• It passes backward and enters the
quadrangular space with the
posterior circumflex humeral artery
• As the nerve passes through the
space, it comes into close
relationship with the inferior aspect
of the capsule of the shoulder joint
and with the medial side of the
surgical neck of the humerus
• It terminates by dividing into
anterior and posterior branches
Axillary Nerve
• branches:
• An articular branch to the
shoulder joint
• An anterior terminal
branch, which winds
around the surgical neck
of the humerus beneath
the deltoid muscle; it
supplies the deltoid and
the skin that covers its
lower part.
Axillary Nerve
• A posterior terminal branch, which gives off
a branch to the teres minor muscle and a
few branches to the deltoid, then emerges
from the posterior border of the deltoid as
the upper lateral cutaneous nerve of the
arm
• The axillary nerve can be injured in
dislocations of the shoulder joint
Suprascapular nerve
Arterial Anastomosis Around the Shoulder
Joint
• The extreme mobility of the
shoulder joint may result in
kinking of the axillary artery and
a temporary occlusion of its
lumen
• To compensate for this, an
important arterial anastomosis
exists between the branches of
the subclavian artery and the
axillary artery
• ensuring that an adequate
blood flow takes place into the
upper limb irrespective of the
position of the arm
Arterial Anastomosis Around the Shoulder Joint
Branches from the Subclavian Artery
• The suprascapular artery, which is
distributed to the supraspinous and
infraspinous fossae of the scapula
• The superficial or transverse cervical
artery, which gives off a deep branch that
runs down the medial border of the
scapula
Branches from the Axillary Artery
• The subscapular artery and its circumflex
scapular branch supply the subscapular
and infraspinous fossae of the scapula,
respectively.
• The anterior circumflex humeral artery
• The posterior circumflex humeral artery
• Both the circumflex arteries form an
anastomosing circle around the surgical
Triangle Of Auscultation
Boundaries-
Below- Horizontal fibres
of latissimus dorsi
Medially- lateral border
of trapezius
Laterally- vertebral
border of scapula
Floor – 6th and 7th rib
Apex of lower lobe of
both lungs lie beneath
this triangle
Scapular Fracture
Is there any problem ?
MCQ
• Injury to which of the following nerve leads to
winging of scapula
a) Long thoracic nerve
b) Thoracodorsal nerve
c) Suprascapular nerve
d) Dorsal scapular nerve
MCQ
• Which of the following group of muscle acts as
lateral rotator of shoulder joint
a) Teres minor and infraspinatus
b) Teres minor and teres major
c) Supraspinatus and infraspinatus
d) Serratus anterior and rhomboids
MCQ
• Which of the following group of muscle acts as
lateral rotator of shoulder joint
a) Teres minor and infraspinatus
b) Teres minor and teres major
c) Supraspinatus and infraspinatus
d) Serratus anterior and rhomboids
MCQ
• Which of the following muscles help in
overhead abduction of arm
• Serratus anterior and trapezius
• Deltoid and supraspinatus
• Supraspinatus and infraspinatus
• Serratus anterior and supraspinatus
