Y, seorang pemuda 14 tahun, mengalami riwayat patah tulang pada

tungkai kaki kiri saat umur 6 tahun dan setelah sembuh

didiagnosis Leg Length Discrepancy (terdapat perbedaan panjang
tungkai kaki kanan dan kiri, yaitu kaki kiri lebih pendek 2 cm
dibandingkan kaki kanan sehingga sulit berlari! "ada masa puber,
sang pemuda juga merasa pertumbuhan tulangnya berbeda
dengan perkembangan tulang teman wanita sekelasnya.
a. struktur tulang panjang
The femur, the long bone in the thigh, illustrates the structure of
bone (fg. 7.1). At each end of such a bone is an expanded portion
called an epiphsis (e!pif" #$!sis)
(plural, epiphses), %hich articulates (forms a joint) %ith another
bone. The epiphsis that is nearest to the trunk of the bod is called
the proximal epiphsis. The one that is farthest from the trunk of
the bod is called the distal epiphsis. &n its outer surface, the
articulating portion of the epiphsis is coated %ith a laer of haline
cartilage called articular cartilage (ar!tik"u!lar kar"t#$!lij). The shaft of
the bone, bet%een the epiphses, is called the diaphsis (di!af" #$!
sis).A tough, 'ascular co'ering of dense connecti'e tis!sue called
the periosteum (per""e!os"te!um) completel encloses the bone,
except for the articular cartilage on the bone(s ends. The
periosteum is frml attached to the bone, and periosteal fbers are
continuous %ith the connecting ligaments and tendons. The
periosteum also helps form and repair bone tissue.
A bone(s shape makes possible the bone(s functions.
)or example, bon projections called processes pro'ide sites %here
ligaments and tendons attach* groo'es and openings form
passage%as for blood 'essels ner'es* and a depression of one
bone ma articulate %ith a process of another.
The %all of the diaphsis is mainl composed of tightl packed
tissue called compact bone (kom"pakt bo+ n), or cortical bone. This
tpe of bone has a continuous extracellular matrix %ith no spaces.
The epiphses, in contrast, are composed largel of spong bone
(spun"je bo+ n), or cancellous bone, %ith thin laers of compact
bone on their surfaces. ,pong bone consists of numerous
branching bon plates called trabeculae (trah!bek"u!le). -rregular
connecting spaces bet%een these plates help reduce the bone(s
%eight (fg. 7..). The bon plates are most highl de'eloped in the
regions of the epiphses that are subjected to compressi'e forces.
/oth compact and spong bone are strong and resist bending.
0ompact bone in the diaphsis of a long bone forms a semirigid
tube, %hich has a hollo% chamber called the medullar ca'it (med
"u!la+r""e ka'" #$!te) that is continuous %ith the spaces of the spong
bone. A thin laer of cells called the endosteum (en!dos"te!um) lines
these areas, and a speciali1ed tpe of soft connecti'e tissue called
marro% (mar"o) flls them.
Tulang paha , tulang panjang di paha , menggambarkan struktur
tulang. 2ada setiap akhir tulang tersebut adalah bagian epiphsis
ang mengartikulasikan ( membentuk sendi ) dengan tulang lain .
3piphsis ang terdekat dengan batang tubuh disebut epiphsis
proksimal . ,alah satu ang terjauh dari batang tubuh disebut
epiphsis distal . 4i permukaan luarna , bagian mengartikulasikan
dari epiphsis dilapisi dengan lapisan tulang ra%an hialin disebut
ra%an artikular ( ar ! tik5u ! lar kar5t# $ ! lij ) . 2oros dari tulang ,
antara epifsis , disebut diaphsis., jaringan ikat padat 'askuler
membungkus tulang .2eriosteum melekat erat ke tulang.
2eriosteum ini juga membantu bentuk dan perbaikan jaringan
tulang .
4inding diaphsis terdiri dari jaringan padat ang disebut tulang
kompak . 6enis tulang memiliki matriks ekstraseluler terus menerus
tanpa spasi . 3pifsis , sebagian besar terdiri dari tulang spons ,
atau tulang cancellous , dengan lapisan tipis tulang kompak pada
permukaan mereka . Tulang spons terdiri dari berbagai cabang
lempeng tulang ang disebut trabekula. 7uang ang
menghubungkan antara lempeng!lempeng ini membantu
mengurangi berat badan tulang. lempeng tulang ang paling
sangat berkembang di daerah epifsis. Tulang kompak dalam
diaphsis tulang panjang membentuk tabung semirigid , ang
memiliki ruang berongga disebut rongga meduler ( med5u !la + r 55 e
ka' 5 # $ ! te ) ang terus!menerus dengan ruang!ruang ang spons
tulang . 8apisan tipis dari sel ang disebut endosteum ( en ! dos5te !
um ) garis daerah!daerah tersebut , dan jenis khusus dari jaringan
ikat lunak ang disebut sumsum ( mar5o ) mengisi mereka .
b. histologi tulang
9icroscopic ,tructure
7ecall from chapter : (p. 1;<) that bone cells called osteoctes
occup 'er small, bon chambers called lacunae, %hich form
concentric circles around central
canals (=a'ersian canals). &steoctes communicate %ith nearb
cells b means of cellular processes passing through canaliculi (fg.
7.>* see fg. :.1?, p. 1;?). The extracellular matrix of bone tissue is
largel composed of collagen and inorganic salts (calcium
phosphate).
0ollagen gi'es bone its strength and resilience, and inorganic salts
make it hard and resistant to crushing.
-n compact bone, the osteoctes and laers of extracellular matrix
concentricall clustered around a central canal form a clinder!
shaped unit called an osteon (=a'ersian sstem). 9an of these
units cemented together form the substance of compact bone.3ach
central canal contains blood 'essels (usuall capillaries) and ner'e
fbers surrounded b loose connecti'e tissue. The blood in these
'essels nourishes bone cells associated %ith the central canal.
0entral canals extend longitudinall through bone tissue, and
trans'erse perforating canals (@olkmann(s canals) connect them.
2erforating canals contain larger blood 'essels and ner'es b %hich
the smaller blood 'essels and ner'e fbers in central canals
communicate %ith the surface of the bone and the medullar ca'it
(fg. 7.>).,pong bone is also composed of osteoctes and
extracellular matrix, but the bone cells do not aggregate around
central canals. -nstead, the cells lie %ithin the trabeculae and get
nutrients from substances diAusing into canaliculi that lead to the
surface of these thin, bon plates.
c. proses pembentukan tulang
As the cartilage enlarges, chondroctes near the center of the shaft
begin to increase greatl in si1e. As these cells enlarge their
lacunae expand and the matrix is reduced to a series of thin struts
that soon begin to calcif. The enlarged chondroctes are no%
depri'ed of nutrients, because diAusion cannot occur through
calcifed cartilage. These chondroctes become surrounded b
calcifed cartilage, die, and disintegrate.
/lood 'essels gro% into the perichondrium surrounding the shaft of
the cartilage. (Be introduced the structure of the perichondrium
and its role in cartilage formation in
0hapter C. p. 1.<) The cells of the inner laer of the perichondrium
in this region then diAerentiate into osteoblasts and begin
producing a thin laer of bone around the shaft of the cartilage. The
perichondrium is no% technicall a periosteum, because it co'ers
bone rather than cartilage.
Bhile these changes are under %a, the blood suppl to the
periosteum increases, and capillaries and fbroblasts migrate into
the heart of the cartilage, in'ading the spaces left b the
disintegrating chondroctes. The calcifed cartilaginous matrix
breaks do%n* the fbroblasts diAerentiate into osteoblasts that
replace it %ith spong bone. /one de'elopment begins at this site,
called the primar ossifcation center, and spreads to%ard both
ends of the cartilaginous model. Bhile the diameter of the
diaphsis is small, it is flled %ith spong bone and there is no
medullar ca'it.
As the bone enlarges, osteoclasts appear and begin eroding the
trabeculae in the center of the diaphsis, creating a medullar
ca'it. )urther gro%th in'ol'es t%o distinct processesD an increase
in length, and an enlargement in diameter b appositional gro%th.
(Be %ill consider appositional gro%th in the next subsection.)
The next major change occurs %hen the centers of the epiphses
begin to calcif. 0apillaries and osteoblasts migrate into these
areas, creating secondar ossifcation centers.
The appearance of secondar ossifcation centers 'aries from one
bone to another and from indi'idual to indi'idual. ,econdar
ossifcation centers ma occur at birth in both ends of the humerus
(arm), femur (thigh), and tibia (leg), but the ends of some other
bones, such as those of the fngers, remain cartilaginous until earl
adulthood.
The epiphses e'entuall become flled %ith spong bone. A thin
cap of the original cartilage model remains ex! posed to the joint
ca'it as the articular cartilage. This cartilage pre'ents damaging
bone!to!bone contact %ithin the joint. At the metaphsis, a
relati'el narro% cartilaginous region called the epiphseal
cartilage, or epiphseal plate, no% separates the epiphsis from the
diaphsis.This micrograph sho%s the interface bet%een the
degenerating cartilage and the ad'ancing osteoblasts. As long as
the epiphseal cartilage continues to gro% at its epiphseal surface,
the bone %ill continue to increase in length.
d. faktor pertumbuhan dan perkembangan tulang
=ormonal and Eutritional 3Aects on /one
Eormal bone gro%th and maintenance depend on a combina!tion of
nutritional and hormonal factors.
F Eormal bone gro%th and maintenance cannot occur %ith!out a
constant dietar source of calcium and phosphatesalts. 8esser
amounts of other minerals, such as magnesium, Guoride, iron, and
manganese, are also reHuired.
F AdeHuate le'els of 'itamin 0 must be present in the diet. The
'itamin, %hich is reHuired for certain ke en1matic reaction in
collagen snthesis, also stimulates osteoblast diAerentiation. &ne of
the signs of 'itamin 0 defciencIa condition called scur'Iis a
loss of bone mass and strength.
F Three other 'itamins ha'e signifcant eAects on bone structure.
@itamin A, %hich stimulates osteoblast acti'it, is paticularl
important for normal bone gro%th in children.
@itamins J and /1. are reHuired for the snthesis of proteins in
normal bone.
F Kro%th hormone, produced b the pituitar gland, and throxine,
from the throid gland, stimulate bone gro%th.
Kro%th hormone stimulates protein snthesis and cellgro%th
throughout the bod. Throxine stimulates cell metabolism and
increases the rate of osteoblast acti'it.
-n proper balance, these hormones maintain normal acti'it at the
epiphseal cartilages until the time of pubert.
F At pubert, rising le'els of sex hormones (estrogens in female and
androgens in males) stimulate osteoblasts to produce bone faster
than the rate at %hich epiphseal cartilage expands. &'er time, the
epiphseal cartilages narro% and e'entuall close. The timing of
epiphseal closure diAers from bone to bone and from indi'idual to
indi'idual. The toes ma complete ossifcation b age 11, but parts
of the pel'is the %rist ma continue to enlarge until about age .:.
4iAerences in male and female sex hormones account for
signifcant 'ariations in bod si1e and proportions. /ecause
estrogens cause faster epiphseal closure than do androgens
%omen are generall shorter than men at maturit.
e. fraktur
jika tulang mengalami fraktur , reaksi pertma adalah pembentukan
hematoma. pembuluh darah pada area cedera mengalami
hemoragi dan pembekuan.
f. proses penembuhan pada fraktur
-n e'en a small fracture, man blood 'essels are broken and
extensi'e bleeding occurs. A large blood clot, or fracture
hematoma, soon closes oA the injured 'essels and lea'es a fbrous
mesh%ork in the damaged area. The disruption of circulation kills
osteoctes around the fracture, broadening the area aAected. 4ead
bone soon extends along the shaft in either direction from the
break.
-n adults, the cells of the periosteum and endosteum are generall
inacti'e. Bhen a fracture occurs, the cells of the intact endosteum
and periosteum undergo rapid ccles of cell di'ision, and the
daughter cells migrate into the fracture 1one. An external callus
(callum, hard skin), or enlarged collar of cartilage and bone, forms
and encircles the bone at the le'el of the fracture. An extensi'e
internal callus organi1es %ithin the medullar ca'it and bet%een
the broken ends of the shaft. At the center of the external callus,
cells diAerentiate into chondroblasts and produce blocks of haline
cartilage. At the edges of each callus, the cells diAerentiate into
osteoblasts and begin creating a bridge bet%een the bone
fragments on either side of the fracture. At this point, the broken
ends ha'e been temporaril stabili1ed.
As the repair continues, osteoblasts replace the central cartilage of
the external callus %ith spong bone. Bhen this con'ersion is
complete, the external and internal calluses form an extensi'e and
continuous brace at the fracture site. ,truts of spong bone no%
unite the broken ends. The surrounding area is graduall reshaped
as fragments of dead bone are remo'ed and replaced. The ends of
the fracture are no% held frml in place and can %ithstand normal
stresses from muscle contractions. -f the fracture reHuired external
support in the form of a cast, that support can be remo'ed at this
stage.&steoclasts and osteoblasts continue to remodel the region of
the fracture for a period ranging from four months to %ell o'er a
ear. Bhen the remodeling is complete, the bone of the calluses is
gone and onl li'ing compact bone remains. The repair ma be
Lgood as ne%M and lea'e no indications that a fracture e'er
occurred, or the bone ma be slightl thicker and stronger than
normal at the fracture site.
Nnder comparable stresses, a second fracture %ill generall occur
at a diAerent site.
g. fraktur pada anak