Anatomy and Physiology

The skeletal system includes all of the bones and joints in the body. Each bone is a complex living organ that is made up of many cells, protein fibers, and minerals. The skeleton acts as a scaffold by providing support and protection for the soft tissues that make up the rest of the body. The skeletal system also provides attachment points for muscles to allow movements at the joints. New blood cells are produced by the red bone marrow inside of our bones. Bones act as the bodys warehouse for calcium, iron, and energy in the form of fat. Finally, the skeleton grows throughout childhood and provides a framework for the rest of the body to grow along with it. Functions of the Skeletal System 1. Support and Protection The skeletal systems primary function is to form a solid framework that supports and protects the body's organs and anchors the skeletal muscles. The bones of the axial skeleton act as a hard shell to protect the internal organs - such as the brain and the heart from damage caused by external forces. The bones of the appendicular skeleton provide support and flexibility at the joints and anchor the muscles that move the limbs. 2. Movement

The bones of the skeletal system act as attachment points for the skeletal muscles of the body. Almost every skeletal muscle works by pulling two or more bones either closer together or further apart. Joints act as pivot points for the movement of the bones. The regions of each bone where muscles attach to the bone grow larger and stronger to support the additional force of the muscle. In addition, the overall mass and thickness of a bone increase when it is under a lot of stress from lifting weights or supporting body weight. 3. Hematopoiesis

Red bone marrow produces red and white blood cells in a process known as hematopoiesis. Red bone marrow is found in the hollow space inside of bones known as the medullary cavity. Children tend to have more red bone marrow compared to their body size than adults do, due to their bodys constant growth and development. The amount of red bone marrow drops off at the end of puberty, replaced by yellow bone marrow. 4. Storage

The skeletal system stores many different types of essential substances to facilitate growth and repair of the body. The skeletal systems cell matrix acts as our calcium bank by storing and releasing calcium ions into the blood as needed. Proper levels of calcium ions in the blood are essential to the proper function of the nervous and muscular systems. Bone cells also release osteocalcin, a hormone that helps regulate blood sugar and fat deposition. The yellow bone marrow inside of our hollow long bones is used to store energy in the form of lipids. Finally, red bone marrow stores some iron in the form of the molecule ferritin and uses this iron to form hemoglobin in red blood cells. 5. Growth and Development Ossification is the process by which bone is formed. Some bones (e.g. the flat bones of the skull) are formed in one stage from the connective tissue. This process is known as intramembranous or direct ossification. Other bones (e.g. short bones) are formed from the cartilaginous model of the future bone developed in the embryo, being dissolved and replaced by bone cells. This process is known as endochondral or indirect ossification most bones are formed this way.

The skeleton begins to form early in fetal development as a flexible skeleton made of hyaline cartilage and dense irregular fibrous connective tissue. These tissues act as a soft,

growing framework and placeholder for the bony skeleton that will replace them. As development progresses, blood vessels begin to grow into the soft fetal skeleton, bringing stem cells and nutrients for bone growth. Osseous tissue slowly replaces the cartilage and fibrous tissue in a process called calcification. The calcified areas spread out from their blood vessels replacing the old tissues until they reach the border of another bony area. At birth, the skeleton of a newborn has more than 300 bones; as a person ages, these bones grow together and fuse into larger bones, leaving adults with only 206 bones. Flat bones follow the process of intramembranous ossification where the young bones grow from a primary ossification center in fibrous membranes and leave a small region of fibrous tissue in between each other. In the skull these soft spots are known as fontanels, and give the skull flexibility and room for the bones to grow. Bone slowly replaces the fontanels until the individual bones of the skull fuse together to form a rigid adult skull. Long bones follow the process of endochondral ossification where the diaphysis grows inside of cartilage from a primary ossification center until it forms most of the bone. The epiphyses then grow from secondary ossification centers on the ends of the bone. A small band of hyaline cartilage remains in between the bones as a growth plate. As we grow through childhood, the growth plates grow under the influence of growth and sex hormones, slowly separating the bones. At the same time the bones grow larger by growing back into the growth plates. This process continues until the end of puberty, when the growth plate stops growing and the bones fuse permanently into a single bone. The vast difference in height and limb length between birth and adulthood are mainly the result of endochondral ossification in the long bones.

The skeletal system in an adult body is made up of 206 individual bones. These bones are arranged into two major divisions: the axial skeleton and the appendicular skeleton. The axial skeleton runs along the bodys midline axis and is made up of 80 bones in the skull, hyoid, auditory ossicles, ribs, sternum, and the vertebral column. The appendicular skeleton is made up of 126 bones in the upper and lower limbs and the pelvic and pectoral (shoulder) girdles. Axial Skeleton 1. Skull

The skull is composed of 22 bones that are fused together except for the mandible. These 21 fused bones are separate in children to allow the skull and brain to grow,

but fuse to give added strength and protection as an adult. The mandible remains as a moveable jaw bone and forms the only movable joint in the skull with the temporal bone. The bones of the superior portion of the skull are known as the cranium and protect the brain from damage. The bones of the inferior and anterior portion of the skull are known as facial bones and support the eyes, nose, and mouth. 2. Hyoid and Auditory Ossicles

The hyoid is a small, U-shaped bone found just inferior to the mandible. The hyoid is the only bone in the body that does not form a joint with any other bone it is a floating bone. The hyoids function is to help hold the trachea open and to form a bony connection for the tongue muscles. The malleus, incus, and stapes - known collectively as the auditory ossicles - are the smallest bones in the body. Found in a small cavity inside of the temporal bone, they serve to transmit and amplify sound from the eardrum to the inner ear. 3. Vertebrae

26 vertebrae form the vertebral column of the human body. They are named by region cervical (neck), thoracic (chest), lumbar (lower back), sacrum, and coccyx (tail bone). There are seven cervical vertebrae, twelve thoracic, five lumbar, one sacrum, and one coccyx. With the exception of the singular sacrum and coccyx, each vertebra is named for the first letter of its region and its position along the superiorinferior axis. For example, the most superior thoracic vertebra is called T1 and the most inferior is called T12. 4. Ribs and Sternum

The sternum, or breastbone, is a thin, knife-shaped bone located along the midline of the anterior side of the thoracic region. The sternum connects to the ribs by thin bands of cartilage called the costal cartilage. There are 12 pairs of ribs that together with the sternum form the ribcage of the thoracic region. The first seven ribs are known as true ribs because they connect the thoracic vertebrae directly to the sternum through their own band of

costal cartilage. Ribs 8, 9, and 10 all connect to the sternum through cartilage that is connected to the cartilage of the seventh rib, so we consider these to be false ribs. Ribs 11 and 12 are also false ribs, but are also considered to be floating ribs because they do not have any cartilage attachment to the sternum at all. Appendicular Skeleton 1. Pectoral Girdle and Upper Limb

The pectoral girdle connects the upper limbs (arms) to the axial skeleton and consists of the left and right clavicles and left and right scapulae. The humerus is the bone of the upper arm. It forms the ball and socket joint of the shoulder with the scapula and forms the elbow joint with the lower arm bones. The radius and ulna are the two bones of the forearm. The ulna is on the medial side of the forearm and forms a hinge joint with the humerus at the elbow. The radius allows the forearm and hand to turn over at the wrist joint. The lower arm bones form the wrist joint with the carpals, a group of eight small bones that give added flexibility to the wrist. The carpals are connected to the five metacarpals that form the bones of the hand and connect to each of the fingers. Each finger has three bones known as phalanges, except for the thumb, which only has two phalanges. 2. Pelvic Girdle and Lower Limb

Formed by the left and right hip bones, the pelvic girdle connects the lower limbs (legs) to the axial skeleton. The femur is the largest bone in the body and the only bone of the thigh (femoral) region. The femur forms the ball and socket hip joint with the hip bone and forms the knee joint with the tibia and patella. Commonly called the kneecap, the patella is special because it is one of the few bones that are not present at birth. The patella forms in early childhood to support the knee for walking and crawling. The tibia and fibula are the bones of the lower leg. The tibia is much larger than the fibula and bears almost all of the bodys weight. The fibula is mainly a muscle attachment point and is used to help maintain balance. The tibia and fibula form the ankle joint with the talus, one of the seven tarsal bones in the foot.

The tarsals are a group of seven small bones that form the posterior end of the foot and heel. The tarsals form joints with the five long metatarsals of the foot. The each of the metatarsals forms a joint with one of the set of phalanges in the toes. Each toe has three phalanges, except for the big toe, which only has two phalanges. Types of Bone 1. Long Bone- consists of diaphysis, epiphysis and medullary cavity. 2. Short Bone- contains more spongy bone than compact; generally cube shape. 3. Flat Bone- thin and flat; has two thin layers of compact bone with spongy bone between them; red blood cells are manufactured here. 4. Irregular Bone- do not fall into proceeding categories, are not symmetrical. Structure of a long bone: 1. Diaphysis is the bones shaft or the body the long bone, cylindrical, main portion of the bone. 2. Epiphyses distal and proximal ends of the bone. 3. Metaphyses regions in mature bone where the diaphysis of the bone to grow in length. 4. Articular cartilage thin layer of the hyaline cartilage covering the epiphysis where the bone forms an articulation with the other bone. 5. Periosteum tough sheath surface wherever it is not covered by articular cartilage. 6. Medullary Cavity or marrow cavity is the space within the diaphysis that contains fatty yellow bone marrow in adults. 7. Endosteum thin membrane that lines the medullary cavity. It contains a single layer of bone-forming cells and a small amount of connective tissue.

Readings
A fracture is a break in the bone or cartilage. It usually is a result of trauma. It can however, be a result of disease of the bone that leads to weakening, such as osteoporosis, or abnormal formation of the bone from congenital diseases at birth, such as osteogenesis imperfecta. Fractures are classified according to their character and location. Examples of classification includes: spiral fracture of the femur," "greenstick fracture of the radius," "impacted fracture of the humerus," "linear fracture of the ulna," "oblique fracture of the metatarsal," "compression fracture of the vertebrae," and "depressed fracture of the skull."

Fractures are named according to their severity, the shape of position of the fracture line. Among the common kind of fractures are the following: BROAD OR GENERAL CLASSIFICATION: Open (compound) Fracture the broken ends of the bone protrude through the skin. Conversely, a closed (simple) fracture does not break the skin. Closed- skin is intact but the bone is broken. Greenstick fracture (Incomplete Fracture) a partial fracture in which one side of the bone is broken and the other side bends: occurs only in children, whose bones are not yet fully ossified and contain more organic material than inorganic material. Complete- if the break completely disrupts the continuity of tissue across the entire with of the bone. Complicated- bone fracture has penetrated on internal structure. ACCORDING TO APPEARANCE: Impacted fracture one end of the fracture bone is forcefully driven into the interior of the other. Simple- bone is broken into two fragments only. Comminuted fracture the bone splinters at the site of impact, and smaller bone fragments lie between the two main fragments. Depressed- the fragments are driven inward. Compressed- bone collapses under excessive fracture.

ACCORDING TO DIRECTION OF THE FRACTURE LINE Transverse- break is straight across the bone Linear- break is along the shaft Oblique- break is diagonal Spiral- break encircles

SPECIAL TYPES OF FRACTURE Potts fracture a fracture of the distal end of the lateral leg bone, with serious Smiths fracture- reverse of Colles fracture. Monteggias facture- fracture of the proximal 3rd of ulna, associated with radial head dislocation. Bennettes fracture- fracture of the base of the thumb, associated with dislocation of metacarpal joint of thumb. Pilon fracture- fracture of the ankle. Cotton fracture- fracture of the malleolus of distal tibia. Galleazzis fracture- fracture of the distal 3rd of radius with associated radiu-ulnar dislocation. Malgaignes fracture- double fracture of the pelvic ring causing instability in the pelvis. Hangmans fracture- fracture of the posterior element of the cervical vertebra with the dislocation of C1 and C2. Neer fracture- fracture of the shoulders and humerus in which the bones are broken into 3 or more fragments.

COLLEs FRACTURE Colles fracture a fracture of the distal end of the lateral forearm bone in which the distal fragment is displaced posteriorly. The Colles' fracture is a specific type of broken wrist. When a patient sustains a Colles' fracture, there is displacement of the bone such that the wrist joint rests behind its normal anatomic position. A Colles' fracture is most commonly found after falling on to an outstretched hand. Depending on the degree of shortening of the forearm bone (radius) and the abnormality of the wrist angulation, a Colles' fracture may need casting or surgery for

treatment. With minimal shortening or displacement, a cast can be the definitive treatment. If the injury is more significant it will likely require operative treatment. The fracture almost always occurs about 1 inch from the end of the bone. The break (fracture) can occur in many different ways, however. A fracture that extends into the joint, it is called an intra-articular fracture. A fracture that does not extend into the joint is called an extra-articular fracture. ("Articular" means "joint.")

Causes The most common cause of a distal radius fracture is a fall on an outstretched hand but it can also be caused by:

Direct blow to wrist by: o Car accident o Falling off a bike o Skiing fall Other trauma

Risk Factors Osteoporosis (decreased density of the bones) can make a relatively minor fall result in a broken wrist. Many distal radius fractures in people older than 60 years of age are caused by a fall from a standing position. Osteoporosis is a disease in which bones become weak and brittle. If left unchecked, osteoporosis can progress painlessly until a Fracture (fracture). Any bone can be affected, but of special concern are fractures of the hips, spine, and wrists. Poor nutrition- Calcium is the major structural component of bones. Calcium helps form a structure called hydroxyapatite, which provides strength to the bones. Approximately 99 percent of the calcium in your body is stored in your bones, with the

remaining calcium circulating in your blood. The calcium in your blood must be tightly regulated for you to stay healthy. If an elderly adult does not consume enough calcium, calcium blood levels drop. This signals the parathyroid gland to release hormones that pull calcium out of the bones to replace blood calcium. Over time, this decreases bone density and can increase the risk of osteoporosis and fractures. Your ability to absorb calcium declines with age Vitamin D allows your small intestine to properly absorb calcium. Without adequate amounts of vitamin D, the body cannot absorb calcium, regardless of how much you consume. There are two ways to meet vitamin D needs: your diet and exposure to sunlight. When exposed to the UV-B rays of the sun, the skin synthesizes vitamin D. As you age, your skin's ability to synthesize vitamin D decreases. In addition, the International Osteoporosis Foundation notes that, in general, elderly people do not go outdoors as much. Vitamin K allows enzymes to regulate a protein called osteocalcin, which binds with calcium to keep bones healthy. According to the International Osteoporosis Foundation, low dietary intake of vitamin K leads to decreased bone mineral density and increased incidence of fractures in elderly adults. Postmenopause- Menopause is characterized by the loss of estrogen production by the ovaries. This may occur by natural means or by the surgical removal of both ovaries. This loss of estrogens accelerates bone loss for a period ranging from 5 to 8 years. In terms of bone remodeling the lack of estrogen enhances the ability of osteoclasts to absorb bone. Since the osteoblasts (the cells which produce bone) are not encouraged to lay down more bone, the osteoclasts win and more bone is lost than is produced.

Conditions that increase risk of falling: Snow Ice Loss of agility or muscle strength If you are elderly

Manifestations

pain Bruising Swelling Tenderness

Severe pain with movement Trouble moving wrist or arm Obvious deformity Loss of normal function Excessive motion at site Crepitus Loss of sensation Vidence of fracture on x- ray film

STAGES OF BONE HEALING 1. Formation of fracture hematoma Because of the fracture, blood vessels crossing the fracture line are broken. This include vessels in the periosteum, haversian system, medullary cavity, and perforating canals. As blood leaks from the torn ends of the vessels, it forms a clot around the site of the fracture. This clot is called fracture hematoma, usually forms around 6-8 hours after the injury. Because the circulation of blood stops at the site where the fracture hematoma forms, nearby bone cells die. Swelling and inflammation occur in response to dead bone cells. Producing additional cellular debris. Blood capillaries grow into the blood clot, and phagocytes and osteoclasts begin to remove the dead or damaged tissue in and around the fracture hematoma. This stage may last up to several weeks. 2. Fibrocartilaginous callus formation The infiltration of new blood capillaries into the fracture hematoma helps organize it into an actively growing connective tissue called a procallus. Next, fibroblast from the periosteum and osteogenic cells from the periosteum, endosteum, and red bone marrow invade the procallus. The fibroblast produce collagen fibers, which helps connect the broken ends of the bone. Phagocytes continue to remove cellular debris. Osteogenic cells develop into condroblasts in areas of avascular healthy bone tissue and begin to produce fibrocartilage. Eventually, the procallus is transformed into a fibrocartilaginous callus, a mass of repair tissue that bridges the broken ends of the bone. Formation of the cartilaginous callus takes about 3 weeks. 3. Bony callus formation In areas to well-vascularized healthy bone tissue, osteogenic cells develop into an osteoblasts, which begin to produce spongy bone trabeculae. The trabeculae join living and dead portions of the original bone fragments. In time, the

fibrocartilage is converted to spongy bone, and the callus is then referred to bony callus. The bony callus lasts about 3-4 months. 4. Bone remodeling The final phase of bone repair is bone remodeling of the callus. Dead portions of the original fragments of broken bone are gradually resorbed by osteoclasts. Compact bone replaces spongy bone around the periphery of the fracture. Sometimes, the repair process is so thorough that the fracture line is undetectable even in a radiograph. Often, a thickened area on the surface of he bone remains as an evidence of a healed fracture, and a healed bone is eventually stronger that it was before the break. Diagnostic Procedures

X-ray - a diagnostic test which uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film. Magnetic resonance imaging (MRI) - a diagnostic procedure that uses a combination of large magnets, radiofrequencies, and a computer to produce detailed images of organs and structures within the body. Computed tomography scan (Also called a CT or CAT scan.) - a diagnostic imaging procedure that uses a combination of x-rays and computer technology to produce cross-sectional images (often called slices), both horizontally and vertically, of the body. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs. CT scans are more detailed than general x-rays.

Treatments 1. Reduction- putting the bone back to its proper alignment. a. Open- involves insertion of screws, pins, rods, wires, nails and plates to keep the bones in its position as it heals. b. Closed-it involved manipulation of the fragments by manual traction, pressure or rotation to lock the ends of fragments together to restore normal bone alignment. 2. Traction- refers to a set of mechanisms for straightening broken bones or relieving pressure on the spine and skeletal system. Purposes: 1. For immobilization. 2. For support.

3. 4. 5. 6.

To reduce fracture. To lessen pain and muscle spasm. To prevent and correct deformity. To maintain good body alignment.

Principles of Traction: 1. 2. 3. 4. 5. The patient must be in supine position. There must be a continuous traction. There must be a counter traction. The line of pull must be in line with the line of deformity. Friction must be avoided.

Methods of applying traction: 1. Manual- applied to the body by the hand by the operator using a firm, steady pull. 2. Mechanical- applied to either skin or bones with the use of ropes pulleys or weights. a. Skin traction- either skin adhesive( this is applied to the skin using adhesive tapes, elastic bandages and spreader) or non- adhesive( applied to the body using devices like canvas, laces, buckles, or leather straps.) b. Skeletal Traction- applied to the bones using pines, wires or tongs. 3. Immobilization- to hold bone fragments in contact with each other until healing takes place. Methods by which immobilization can be achieved: 1. Splinting 2. External fixator 3. casting