PECTORAL REGION AND BACK

ACTIVITY 1: PECTORAL GIRDLE

 
The clavicle and scapula together form the pectoral girdle.
 
a. Describe the clavicle highlighting its characteristics.
 
b. Label the diagrams of the clavicle below.
 

 
 
 
 
 

c. List the muscles attached to the clavicle. Shade the attachments of the muscles in the diagrams
above.

 Superior surface and anterior border  Deltoid muscle

 Superior surface                                Trapezius muscle
 Inferior surface                                  Subclavius muscle
 Anterior border                                 Pectoralis major muscle
 Posterior border                               Sternocleidomastoid muscle (clavicular head)
 Posterior border                               Sternohyoid muscle
 Posterior border                               Trapezius muscle

 
d. Describe the scapula.
Scapula is the bone that connects the humerus (arm bone) with the clavicle (collar bone). The
scapula forms the posterior (back) located part of the shoulder girdle. In humans, it is a flat bone,
roughly triangular in shape, placed on a posterolateral aspect of the thoracic cage. Structurally, it is
divided into anterior and posterior surface. 
 Posterior side:  spine of scapula, acromion, supraspinous fossa, infraspinous fossa
 Anterior side:  coracoid process, subscapular fossa, suprascapular notch, superior angle,
inferior angle, lateral (axillary) border, medial (vertebral) border
 Lateral side:  glenoid cavity
Function of scapula: The scapula is the mobile bone to which most of the shoulder muscles are
attached. It is attached to the back by other muscles. It serves as a broad plate for the strong
anchoring of muscles of the upper extremity. 
 
e. Label the diagrams of the scapulae below.

 
1.  Acromion process
2. Coracoid process
3. Glenoid fossa/Glenoid cavity
4. Infraglenoid fossa/tubercle
5. Subcapsular fossa
6. Lateral border
7. Infraspinous fossa
8. Superior angle
9. Spine
10. Medial border
11. Inferior angle
12. Supraglenoid tubercle
13. Superior angle
f. List the muscles attached to the scapula. Shade the attachments of the muscles in the diagrams
below.
 

 
 
ACTIVITY 2: FRACTURE OF CLAVICLE
 
a. State the weakest point of the clavicle.
Middle third of its length.
 
b. How does fracture of the clavicle occur?
The lateral fragment is depressed by the weight of the arm and is pulled medially and forward by
the strong adductor muscles of the shoulder joint, especially the pectoralis major. The part of the
clavicle near the center of the body is tilted upwards by the sternocleidomastoid muscle. 
Children and infants are particularly prone to it. Newborns often present clavicle fractures following
a difficult delivery.

c. In fracture of the clavicle, describe and explain the position of the clavicular fragments.

After fracture of the clavicle, the sternocleidomastoid muscle elevates the proximal fragment of the
bone. The trapezius muscle is unable to hold up the distal fragment owing to the weight of the upper
limb, and thus the shoulder droops. The adductor muscles of the arm, such as the pectoralis major,
may pull the distal fragment medially causing the bone fragments to override.
 
d. Name the structures that will be at risk of injury in fracture of the clavicle.
 Fractures of the middle third of the clavicle have been associated with damage to the
neurovascular bundle and the pleural dome.( However, more often than not, this injury is
merely cosmetic.)
(Complications occurring after fractures of the medial third of the clavicle resemble those
associated with posterior SC dislocations. )
 Injuries to intrathoracic and superior mediastinal structures may be complications in as
many as 25% of posterior dislocations. Neurovascular injury, pneumothorax, and
hemothorax have been reported.
 Lateral clavicular fractures and injuries to the AC joint can result in cosmetic deformity or
eventually lead to the persistence of nuisance symptoms (eg, clicking, pain). Failure of the
bone to unite after these injuries can also lead to progressive shoulder deformity, impaired
function, and neurovascular compromise. Fractures of the coracoid process can be
complications of AC joint injuries.

 e. How is an uncomplicated fracture of the clavicle treated?

 
 
ACTIVITY 3: ANTERIOR THORACOAPPENDICULAR MUSCLES
 
a. List and describe the anterior thoracoappendicular muscles.
 

b. Describe clavipectoral fascia.

 
 
ACTIVIVTY 4: WINGED SCAPULA
 
a. Describe “winged scapula”.

Medial border or inferior angle of scapula protrude slightly from body. A winged scapula condition
may be accompanied by a protracted shoulder girdle. Risk of shoulder injury is compounded with a
supraspinatus weakness or an external shoulder rotation inflexibility. Because of the forward tilt of
the scapula, complete flexion or external rotation of the shoulder may be seemingly restricted. A
winged scapula condition indicates a serratus anterior weakness. The rhomboids may be weak and
the pectoralis minor may be short. A winged scapula is considered normal posture in young
children, but not older children and adults
 
b. What cause “winged scapula”? 
A winging scapula is associated with damage or a contusion to the long thoracic nerve of the
shoulder and / or weakness in the serratus anterior muscle. If the long thoracic nerve is damaged or
bruised it can cause paralysis of the serratus anterior muscle and winging of the scapular or shoulder
blade.
Damage to the nerve can be caused by a contusion or blunt trauma of the shoulder, heavy weight
lifting, repetitive throwing, traction of the neck or can also sometimes follow a viral illness. Some
cases of long thoracic nerve injury are of unknown origin.

 
c. What will be the disability of a person with a “winged scapula”?
 Pain and limited shoulder elevation.
 Difficulty in lifting weights.
 Patients can complain of pressure on the scapular from a chair when sitting.
 
 
ACTIVITY 5: POSTERIOR THORACOAPPENDICULAR AND SCAPULOHUMERAL
MUSCLES
 
a. List and describe the posterior thoracoappendicular muscles.
 
b. List and describe the scapulohumeral muscles.
 
 
ACTIVIVTY 6: PARALYSIS OF LATISSIMUS DORSI AND TRAPEZIUS MUSCLES
 
a. How do latisimus dorsi and trapezius muscles become paralyzed?
 
b. Describe the disabilities in paralysis of latissimus dorsi and trapezius muscles.
 
 
ACTIVIVTY 7: ROTATOR CUFF MUSCLES
 
a. List the rotator cuff muscles.
 
 Origin on Attachment on
Muscle Function Innervation
scapula humerus
Supraspinatus supraspinous
greater tubercle abducts the arm Suprascapular nerve (C5)
muscle fossa
Infraspinatus infraspinous externally rotates the Suprascapular nerve (C5-
greater tubercle
muscle fossa arm C6)
Teres minor externally rotates the
lateral border greater tubercle Axillary nerve (C5)
muscle arm
Upper and Lower
Subscapularis subscapular internally
lesser tubercle subscapular nerve (C5-
muscle fossa rotates the humerus
C6)

 
ACTIVITY 8: ROTATOR CUFF INJURIES
 
a. Describe rotator cuff injuries and subacromial
bursitis.                                                                                              
 
 
Rotator cuff tear
The tendons at the ends of the rotator cuff muscles can become torn, leading to pain and restricted
movement of the arm. A torn rotator cuff can occur following a trauma to the shoulder or it can
occur through the "wear and tear" of tendons, most commonly that of the supraspinatus under
the acromion. It is an injury frequently sustained by athletes whose duties involve making repetitive
throws, such as baseball pitchers, American football quarterbacks, volleyball players (due to their
swinging motions), water polo players, shotput throwers (due to using poor technique), swimmers,
boxers, kayakers, fast bowlers in cricket, tennis players (due to their service motion),and Wii
players. This type of injury also commonly affects conductors (music), choral conductor, orchestral
conductor,and drummers due to the swinging motions and other movements used to lead their
ensemble. It is commonly associated with motions that require repeated overhead motions or
forceful pulling motions.

Rotator cuff impingement

A systematic review of relevant research found that the accuracy of the physical examination is
low.The Hawkins-Kennedy test  has a sensitivity of approximately 80% to 90% for detecting
impingement. The infraspinatus and supraspinatus tests have a specificity of 80%.
 
 
Subacromial bursitis is a condition caused by inflammation of the bursa that separates the superior
surface of the supraspinatus tendon (one of the four tendons of the rotator cuff) from the overlying
coraco-acromial ligament, acromion, coracoid ( the acromial arch) and from the deep surface of the
deltoid muscle . The subacromial bursa helps the motion of the supraspinatus tendon of the rotator
cuff in activities such as overhead work.
Primary inflammation of the subacromial bursa is relatively rare and may arise from autoimmune
inflammatory conditions (rheumatoid arthritis), crystal deposition (Gout or Pseudo gout), calcific
loose bodies (rheumatoid arthritis) and infection . More commonly, subacromial bursitis arises as a
result of complex factors, thought to cause shoulder impingement symptoms. These factors are
broadly classified as intrinsic (intratendinous) or extrinsic (extratendinous). They are further divided
into primary or secondary causes of impingement. Secondary causes are thought to be part of
another process such as shoulder instability or nerve injury.