Bones can be divided into 3 generic groups: long bones, short bones, and flat bones.

[1, 2, 4]

Long bones are formed from a cartilage model precursor by endochondral ossification (see
the image below) and can range in size from a phalanx to a femur. They are typically tubular,
have distinct anatomic zones, and are longer than they are wide. [1, 2, 4] Short bones arise from
the same precursors but are not necessarily structurally similar to long bones, often taking on
unique shapes (eg, carpal bones). Flat bones are formed without a precursor by
intramembranous ossification [1] and can have unusual shapes (eg, skull or sternum).

Endochondral ossification of long bones

through cartilage precursor.
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Most bones have a thick, well-organized outer shell (cortex) and a less dense mesh of bony
struts in the center (trabecular bone) (see the image below). The ratio of cortical bone to
trabecular bone varies widely; [5] in adults, this ratio is typically 80:20. [4]

Trabecular and cancellous bone.

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The only bones that lack a true cortex are the vertebrae, which are covered by a compact
condensation of trabecular bone. [1] All bones are encased in a soft tissue envelope known as
the periosteum, which is vital for perfusion and nutrient supply to the outer third of the bone
(see the image below). [1, 2] The remainder of the blood supply is through nutrient vessels that
pierce the cortex and supply the marrow cavity and the inner two thirds of the cortical bone. [1,
2]

Anatomy of bone.
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Long bones

Mature long bones have 3 distinct zones: epiphysis, metaphysis, and diaphysis (see the image
below). [1] In development, the epiphysis and metaphysis are separated by a fourth zone,
known as the epiphyseal plate, or physis. This segment of the bone is cartilaginous and is the
region from which the bone grows longitudinally. By adulthood, all epiphyseal plates have
closed down, and a bony scar is all that remains of this important structure. Long bones
include the femur, tibia, fibula, humerus, radius, ulna, metacarpals, metatarsals, and
phalanges.

Zones of mature long bone.

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Epiphysis

The epiphysis is the region at the polar ends of long bones. Most commonly associated with
joint surfaces, it usually comprises a thin, compact bone shell with a large amount of bony
struts (trabecular bone) for support of the cortical shell. The network of bony struts below the
compact shell is ideally suited for its job as a shock absorber. [1]

The shell or covering of compact bone is thicker just below a joint and is known as the
subchondral bone; it supports the hyaline articular cartilage of the joint just above it. The
subchondral bone is not true cortical bone, in that it lacks some of the organization of cortical
bone. [1]
The epiphysis also serves as an attachment region in many bones, allowing joint capsular
attachments, many ligamentous attachments, and some tendinous attachments as well. Like
most sections of bone, it is strong, but it lacks the rigidity of the diaphysis.

Epiphyseal plate (physis)

An extremely important zone in human development, the epiphyseal plate is responsible for
longitudinal growth of the skeleton and therefore one's height and stature. There are many
diseases of the epiphyseal plate such as achondroplasia that affect the plate’s ability to grow
normally and this can lead to significant change in stature and are often know as the skeletal
dysplasias. The epiphyseal plate itself is broken down into distinct zones (see the image
below).

Zones of epiphyseal plate.

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There is a layer of resting cartilage that is the precursor to the process. Cells are stimulated to
replicate in the zone of proliferation, and chondrocytes then hypertrophy in the zone of
hypertrophy. They then undergo a process of mineralization, and eventually death, in the zone
of calcification. This forms the bone precursor that will continuously be remodeled
throughout life. Bones can also grow in width from direct bone formation supported by the
periosteum.

Metaphysis

The metaphysis is a transitional zone between the epiphysis and diaphysis. It is also
characterized by thinner cortical walls with dense trabecular bone. It is commonly the site of
tendinous attachments to bone. It is a metabolically active region and often supports a fair
amount of bone marrow. The metaphysis is the region where the bone made by the epiphyseal
plate is fine-tuned into its diaphyseal shape.

Diaphysis

In the middle of long bones is the diaphysis, a segment of thick cortical bone with a minimal
amount of trabecular bone. It is often smaller in diameter than metaphyseal and epiphyseal
bone; because its thick cortical layer is extremely strong, it does not require a large diameter
to distribute its load. The central portion is the least dense area of the bone and is known as
the intramedullary canal. The area of the bone inside the cortex is continuous throughout an
entire bone and is known as the endosteal area. [1]
Diaphyseal bone’s primary function is structural: it gives the skeleton much of its length and
providing much of the surface area for muscular and tendinous attachment.

Short bones

Short bones are also formed by the same cartilage precursor model as long bones; however,
they tend to have unique shapes and functions. They provide less overall height than long
bones. Like long bones, they have a cortical shell on the periphery and a trabecular inner
portion. They vary in size and shape. Examples include the carpal bones, vertebrae, patella,
and sesamoid bones.

Flat bones

Although similar to the previously mentioned bones in some respects, flat bones differ
completely in their embryologic origin. Stemming from mesenchymal tissue sheets, flat
bones never go through a cartilaginous model. The mesenchymal sheets condense and
organize and are eventually ossified. They grow from membranous or periosteal growth.
They consist of a cortical shell with a cancellous interior and are often broad and flat. They
provide protection (eg, skull) and also offer wide, flat surfaces for muscular attachment (eg,
scapula).

The skeleton is divided into 2 anatomic regions: axial and appendicular (see the images
below). The appendicular skeleton comprises the extremities, which are paired mirror images
of each other. The axial skeleton is the central structural core of the body. The auditory
ossicles and the hyoid bone are nonstructural, nonextremity bones that are used in sensation,
phonation, and swallowing; they do not fit well into either category.

Human skeleton.
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 Axial and appendicular skeletal systems. Axial
skeleton is green; appendicular skeleton is purple.
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The axial skeleton includes the bones of the skull, cervical vertebrae, thoracic vertebrae, ribs,
sternum, [1] lumbar vertebrae, [5] and the sacrum and coccyx (see the image below). Some
authors consider the bones of the pelvis to be axial, although they properly belong to the
appendicular skeleton.

Human spine from C1 to sacrum. Note different

curves, from lordosis (cervical) to kyphosis (thoracic) and then back to lordosis (lumbar).
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The skull is made of many interdigitating flat bones with numerous sinuses, foramina, and
features; detailed discussion of these features is beyond the scope of this article. The main
joints of the skull are the articulations between the mandible and skull and the articulation
between C1 and the base of the skull. The skull’s primary purpose is to house the brain and
sensory organs. The bones of the skull also allow mastication, swallowing, phonation, and
numerous other vital functions.

The cervical spine is made up of 7 vertebrae (see the first and second images below). C1 and
C2 are highly specialized and are given unique names: atlas and axis, respectively (see the
third image below). C1 and C2 form a unique set of articulations that provide a great degree
of mobility for the skull. C1 serves as a ring or washer that the skull rests upon the dens or
odontoid process of C2. Approximately 50% of flexion extension of the neck happens
between the occiput and C1; 50% of the rotation of the neck happens between C1 and C2.

Cervical spine anatomy.

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Lateral radiograph of cervical spine

showing all 7 vertebrae.
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 Cervical spine. Note uniquely shaped atlas and
axis (C1 and C2).
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Illustration of cervical vertebrae, showing body,

pedicles, lamina, facets, transverse processes, spinous process, and neural elements.
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C3-7 are more classic vertebrae, having a body, pedicles, lamina, spinous processes and facet
joints. The cervical spine is highly mobile. The other unique feature of cervical vertebrae is
that they contain transverse foramina for the vertebral arteries as they travel cephalad,
encased in bone at each level.

The thoracic spine is typically made up of 12 vertebrae. These vertebrae also have a body,
pedicles, laminae, spinous processes, and facet joints (see the first two images below).
Additionally, they have prominent lateral processes that form the articulation with the paired
12 ribs on either side. The 12 vertebrae, 24 ribs, and sternum together form the chest cavity,
allowing negative-pressure respiration and providing protection of the chest wall (see the
third image below). The thoracic spine is highly immobile.

Illustration of thoracic vertebrae showing

vertebral body, pedicles, facets, transverse process, rib joints, spinous process, and lamina.
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 Lateral projection radiograph of child's thoracic spine.
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Illustration of rib cage, demonstrating ribs and

connection through cartilage to sternum. This cage protects vital organs and is essential for
creating negative pressure to inflate lungs.
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The lumbar spine is the next mobile segment of the spine, typically consisting of 5 large
vertebrae with classic features, including body, pedicles, lamina, spinous processes, facet
joints, and lateral processes (see the image below). The lumbar spine is mobile with all
articulations, contributing to flexion-extension, bending, and rotation. The lumbar spine
allows truncal mobility.

The lumbar spine connects to the sacrum through the L5-S1 articulation (see the images
below). The wedge-shaped sacrum is a fused set of sacral vertebrae. Its primary purpose is to
transfer the load from the spine to the pelvis. This happens through the extremely strong and
immobile sacroiliac joints. The sacrum also houses the sacral nerve roots from the terminal
end of the spinal canal. At the end of the sacrum is the coccyx, which is the vestigial remnant
of the tail.
 Lumbar vertebrae are characterized by massive bodies
and robust spinous and transverse processes. Their articular facets are oriented somewhat
parasagittally, which is thought to contribute the large range of anteroposterior bending
possible between lumbar vertebrae. Lumbar vertebrae also contain small mammillary and
accessory processes on their bodies. These bony protuberances are sites of attachment of deep
lumbosacral muscles.
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Lateral radiograph of lumbar spine and sacrum.

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Sacrum. This structure is essentially multiple

fused vertebrae. Note foramina (holes) for sacral nerve roots.
Upper extremity

The upper extremities are mirrored paired structures. The upper extremity starts at the
shoulder girdle and extends to the finger tips. The shoulder girdle consists of the scapula and
the clavicle (see the first and second images below). The clavicle is an S-shaped bone that
provides a strut on which the shoulder girdle articulates (see the third image below). It
originates at the sternoclavicular joint and terminates at the acromioclavicular joint.

Shoulder girdle, composed of clavicle and

scapula.
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Anterior-posterior radiograph of shoulder girdle,

including scapula, humerus, and clavicle.
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 Clavicle.
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The scapula is a multifunctional bone. Its body (the wide and flat medial portion) is the site of
origin of the rotator cuff muscles. Additionally, the scapula articulates with the chest wall to
give the shoulder a greater net motion that could be achieved with just glenohumeral motion.
The body of the scapula then turns into the neck and flattens into the shallow glenoid cavity.

The glenoid cavity is the socket of the ball-and-socket joint of the shoulder (the glenohumeral
joint). It is a deficient socket, being very flat. Accordingly, the soft tissue labrum, ligaments,
and muscular attachments are crucial in stabilizing this joint.

In addition, the scapula has a process that protrudes superiorly and another that protrudes
anteriorly. These are called the acromion and the coracoid, respectively, and both serve 2
functions. The primary function is soft tissue attachment: the deltoid to the acromion and the
conjoint tendon to the coracoid. The secondary function is secondary stabilization of the
glenohumeral joint.

Arm

The only bone of the arm is the humerus. This bone starts with a ball-and-socket type joint at
the glenohumeral articulation and terminates at the elbow in a hingelike joint (see the images
below). The humerus is a long tubular bone. Its proximal portion allows highly mobile
motion at the shoulder. Its shaft has numerous muscular attachments for muscles controlling
shoulder motion and elbow motion. There are even muscles acting distal to forearm that
attach on the humerus and cross multiple joints.
 Humerus. This is sole bone of upper arm and has both
ball-and-socket joint (shoulder proximally) and hinge joint at elbow. Capitulum is specialized
portion of hinge joint that allows radial head rotation in all planes of flexion and extension for
forearm pronation and supination.
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Anterior-posterior radiograph of humerus.

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Forearm

The forearm is made up of the radius and the ulna (see the images below). The ulna is the
principal weight-bearing articulation at the elbow through the olecranon. The radius is the
principal weight-bearing articulation at the wrist. The load is transitioned between the 2
through the syndesmotic interosseous ligament. The anatomy of the radius and ulna allow
pronation and supination of the wrist.
 Bones of forearm: radius and ulna. Ulna is primary
articulation at elbow, radius at wrist.
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Anterior-posterior radiograph of
radius and ulna.
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Wrist

The wrist comprises 7 bones: scaphoid, lunate, triquetrum, pisiform, trapezoid, trapezium,
capitate, and hamate (see the images below). The bones are divided into 2 rows: proximal and
distal.

Carpal bones, metacarpals, and phalanges are all shown.

Note that thumb has only 2 phalanges, whereas remaining fingers have 3 each.
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 Anterior-posterior radiograph of carpal bones at wrist.
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All of the bones of the wrist are small and unique in shape. The scaphoid, lunate, triquetrum,
and pisiform make up the proximal row and primarily articulate with the distal radius. This
complex articulation accounts for a high proportion of wrist flexion/extension and
radial/ulnar deviation. The proximal row and distal row are intimately connected and have
multiple ligamentous structures to stabilize them. The metacarpals articulate with the distal
row.

Hand and fingers

The hand is made up of multiple rays of bones (see the image below). Each finger starts as a
metacarpal, which is a long tubular bone that articulates with the distal row of carpal bones
and other metacarpals proximally. Metacarpals have a rounded articular surface at the distal
end that forms the metacarpophalangeal (MP) joint. The metacarpals (except for the thumb
metacarpal) are relatively immobile, owing to the numerous ligamentous connections in the
palm.

Anterior-posterior radiograph of bones of hand and fingers.

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The unique thumb metacarpal articulates with the trapezium through a saddle-type joint
known as the carpometacarpal (CMC) joint. This highly mobile joint enables thumb
opposition and is crucial to grip and hand function. The thumb also has the unique feature of
possessing only having 2 phalanges, proximal and distal, and thus only 1 interphalangeal
joint. The remainder of the fingers are made up of 3 phalanges, each of which is a short
tubular structure joined to the others through the proximal and distal interphalangeal joints.

Lower extremity and pelvis

The lower extremities are mirrored paired structures. The lower extremity starts at the pelvis
and extends to the toes.

Hip bone

The os coxae, or hip bone (see the images below), is occasionally (and incorrectly)
considered part of the axial skeleton. It is a fusion of 3 bones bilaterally (6 total): ilium,
ischium, and pubis.

Illustration of pelvic girdle demonstrating

connection of ilium to sacrum, ischium, and pubis.
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Anterior-posterior radiograph of pelvis,

demonstrating pelvic girdle and connection to sacrum.
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The ilium is a large, curving flat-type bone that connects the sacrum to the pelvic girdle. It
has a very broad area of muscle attachment and many palpable bony prominences, such as the
anterior superior iliac spine (ASIS). The ischium attaches to the ilium at the acetabulum and
makes up the bony floor of the pelvis. It also has many muscular and ligamentous
attachments. It is the bone that one sits on when seated.
The pubis also connects to the ilium and ischium at the acetabulum and forms the superior
anterior portion of the ring. The anterior midline bony prominence that can be palpated
represents the pubic bones coming together in the front at the symphysis pubis.

The 3 bones are fused and contribute to the acetabulum, a cup-shaped fossa that is the socket
of the ball-and-socket hip joint (see the image below). In addition to the spine, the hip bone is
the most important source of bone marrow in adult life.

Unilateral side view of hip bone demonstrating

confluence of 3 bones of hip bone at acetabulum.
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Femur

The femur (see the images below) is the longest and strongest of the human bones.
Proximally, the femur is the ball of the ball-and-socket joint of the hip (a highly congruent
joint). The femoral head is grossly spherical in nature, permitting a great deal of joint motion
in all planes. It has a tenuous blood supply and is sensitive to avascular necrosis.

Femur. Note 2 articulations at either end; hip is ball-

and-socket joint, whereas knee is unstable hinge joint. Femoral neck is angulated and
anteverted relative to shaft.
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 Anterior-posterior radiograph of entire femur.
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The femoral head is attached to the femur through the femoral neck. The femoral neck is
angled approximately 135 degrees in the coronal plane and approximately 20-30 degrees in
the sagittal plane relative to the femoral shaft, with allowances for lateral offset of the shaft.
This orientation gives the muscles working around this joint much more power, because of
their extended lever arm.

The femoral shaft is long and tubular, with a gentle bow in the anteroposterior direction. It
terminates at the femoral condyles, which make up half of the knee joint. It takes an immense
amount of force to break a femur in a healthy individual; fracture of this bone is a marker of
severe trauma.

Patella

The patella (see the image below) is essentially a giant sesamoid bone. It lies within the
tendon of the quadriceps femoris and moves the tendon away from the center of joint rotation
to give the muscles a greater mechanical ability to move the joint in extension. The patella
can be subjected to as much as 8 times a person's body weight when the knee is actively in
use. It has the thickest articular cartilage of any bone and rides in a groove between the
medial and lateral femoral condyles (known as the trochlea).

Lateral radiograph of patella with

knee in near extension.
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Tibia

The tibia (see the images below), commonly referred to as the shin bone, starts proximally as
a wide, nearly flat surface called the tibial plateau, with which the femoral condyles articulate
to form the knee joint. Because the condyles are rounded and the plateau is minimally
concave, this joint is inherently unstable and requires multiple soft tissue supporting
structures for stability. The knee joint mostly flexes and extends but does allow some internal
and external rotation.

Tibia and fibula. Proximal tibia makes up entire articulation

of knee joint, and distal tibia makes up majority of ankle joint.
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Anterior-posterior radiograph of tibia and fibula.

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The tibial shaft is triangular and strong and, like the femur, has a slight bow. It terminates at
the ankle joint, where the tibia forms a flat weight-bearing portion of the ankle (the plafond)
and the medial stabilizer of the joint (the medial malleolus).

Fibula

The fibula is an interesting bone, in that it bears no weight but nonetheless has crucial
functions in knee and ankle articulation. At the knee, the fibular head articulates (minimally)
with the proximal tibia and is crucial for the attachment of soft tissues, including the lateral
collateral ligament (LCL), for knee stability.
The midshaft of the fibula has muscular attachments but is not essential and is often
harvested if vascularized bone autografts are needed for reconstructions. The distal end
makes up the strong tibiofibular joint and the lateral aspect of the ankle joint. The fibula and
tibia are tightly connected through a set of strong soft tissue ligaments called the syndesmotic
complex.

Talus

The talus has 2 distinct regions: body and head. These are connected through the talar neck.
The body has a large superior dome that fits inside the box made up of the fibula, the tibial
plafond, and the medial malleolus. This joint is what is considered the ankle joint (see the
images below); it allows dorsiflexion and plantar flexion of the foot.

Mortise ankle radiograph.

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Lateral foot radiograph.

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On the underside of the talar body and head is a series of complex articulations with the
calcaneus; these are known as the subtalar joints. The subtalar joints allow inversion and
eversion of the hind foot. The talar head articulates with the navicular to form one of the
hindfoot-midfoot connections.

Calcaneus

The calcaneus (see the image below) is a large, uniquely shaped bone. It makes up the
remainder of the articulations with the midfoot and subtalar joint.
 Bones of foot. All segments of foot, including hindfoot,
midfoot, and forefoot, are represented.
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The calcaneus is the location of the calcaneal (Achilles) tendon attachment and therefore is
where the muscles act to achieve plantar flexion of the foot. It also is the only bony
component of the heel and therefore is subject to fracture in falls or trauma when a person
lands on his or her feet. The calcaneus is the proximal extent of the soft tissue "windlass"
mechanism that makes up the arch of the foot and is a common site of pain in disorders such
as plantar fasciitis.

Midfoot and forefoot

Like the bones of the wrist, the midfoot is made up of a series of uniquely shaped bones that
are all intimately connected to each other (see the image below). As a group, these bones
allow significant motion, but individually, they have little articular motion. The bones of the
midfoot include the navicular, cuboid, medial cuneiform, middle cuneiform, and lateral
cuneiform.

Anterior-posterior weight-bearing radiograph of foot. Note open physis in

foot, signifying pediatric patient.
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The forefoot consists of the 5 metatarsals, which are long tubular bones radiating out from the
midfoot to the toes. Each toe has its own metatarsal. The metatarsal heads make up the
primary weight-bearing surface of the forefoot. All 5 are strongly connected through a series
of soft tissue connections, especially between the proximal first and second metatarsal. At the
ends of the metatarsals are the toes, each consisting of 3 phalanges (except the first, which,
like the thumb, has only 2).