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    Tugas 1

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    M25 Bhayangkara
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    of 14
    2 Normal Structure and Function of Musculoskeletal Tissues Having completed the preclinical phase of your undergraduate coune, you will have learned much about the embryology, anat- ‘omy, histology, biochemistry and physiology of the musculoskeletal tissues in humans. Tis, isextremely important, because to understand. the abnormal, you must have an understand: ing ofthe normal indeed, your knowledge of the normal will serve asa broad base on whieh to build a knowledge of the abnormal. Some of the more important aspects of this broad base are reviewed to reesh your memory and to prepare you for subsequent study of the abnormal clinical conditions of the muscu: skeletal system (also known as the locomotor system). BONES AS STRUCTURES AND BONE AS AN ORGAN “The tissue bone is considered from two en tirely different points of view: 1) individual bbones are anatomical structures and 2) bone ofthe entre skeleton collectively ia plysolen cal organ that is metabolically active. Since the nonliving intercellular matrix of bone iscakified, or stoncike itis one of the hard tissues. Indeed, its hardness provides the strength to individual bones a strucrs and enables them to serve three functions: 1) to provide the rigid framework fr the trunk and extremities to withstand mechanical loads; 2) to serve as levers for the locomotor function of skeletal muscles; 3) to afford protection for vulnerable viscera for example, the skull for the bran, the spine for the spinal cord, and the thoracic eage forthe heartand lungs. Bone ‘of the entire skeleton as an oxgan serves 10 aaditional funetions: 4) it contains hemopoi cc tissue ofthe myeloid type forthe produc: “Anatanny isto plsilegy as geagraphy isto his tory: it desribes the theatre of events.” —Jean Ferme (1497-1558) ‘On the Natural Part of Medicine (Ch. 1) tion of enthrocytes, granular leukocytes, and platelets and 5) itis the organ of storage or reservoir for calcium, phosphorus, magne~ sium, and sodium, helping to maintain the “miliew intérieur” of ionized mineral homeo stasis by storing or releasing these substances as the need arises, Thus, in addition to being bone forming ‘ells, osteoblasts also govern metabolism in response to a wide variety of stimuli—bio- chemical, mechanical, electrical, and mag netic —via specifi cellular receptors. Embryonic Development of Bones In the intial stages of development, the tube shaped embryo contains three primary germ cell layers: the ectoderm or covering layer, the ‘endoderm or lining layer, and the mesoderm or ‘midale layer. From the mesoderm comes the amcsenclyme, 2 diffuse cellular tissue that ex- Iibis pluripotentility inthe sense tha its un sltlrentiated cells are capable of ing into any one of several types of connestive tissue such as bone, cartilage, ligament, mus- cle, tendon and fascia. Bone and cartilage, being able to support weight through their non-living intercellular substances, may be ‘thought of as supporting connective tists, Diuring the filth week of embryonic devel ‘opment, the limb buds, covered by ectoderm, appear. In the central axis of each limb bud, the mesenchymal cells become condensed into a shore cylinder. This cylinder is seg: mented by less densely cellular areas at the sites of urure joins and each segment repre seats a tiny mexenchymal model of the Future long bone that will develop from it (Fig. 2.1) By the sixth embryonic week, the undifren 7 Section | Basic Musculoskeletal Science PeRICHORORUN ARILAGE nee & were CARTILAGE MODEL Figure. pene tiated mesenchymal cells of each model begin to differentiate by manufacturing. cartilage matrix and thereby forming a cartilaginous ‘model of the future bone. The cartilaginous model grows partly from within (intersirial growth) and parly through the apposition of ‘new cells on its surface (appositional growth ) fiom the deeper layers of the perichondrium (Fig. 2.1). After the seventh week of embryogenesis, the cartilage cells in the center of the model ihyperropiy and form longitudinal rows after which the intercellular substance, or matrix, ‘ake, resulting in cel death. Vascular con” nective issue then grows into the central area ‘of dead cartilage bringing asteoblats that s¢- ‘rete collagen and proteogleans into the ma- trix; the matrix is then impregnated with eal- cium saltsand becomes immature bone on the caleified cartilage matrix, thereby forming the primary center of osification. This process of replacement of cartilage by bone is called en- dochoniral osification and i occurs only in the presence of capillaries. The endochondral ossification advances toward each end of the ‘arilage model, which, in tur, continues to sgrow in length a its cartilaginous ends by i tersttal growth. The perichondrium has by thistime become periosteum, and in ts deeper layer, the mesenchymal cells, which have di ferentiated into osteoblasts, Iay down bone directly by the process of intramembranous sification, there being no intermediate cartilaginous phase (Fig. 2.1) Embryonic development ofa long bone during the fist 6 months of embryo By the sith month of embryonic develop- ment, resorption ofthe central par ofthe ong, tone results in the formation of a medullary cavity—the proces of tabulation, At the time of birth, the largest epiphysis in the body (dis- tal femoral epiphysis) has developed a second- any center of eifcation by the process of en- dochondral osiication within it (Fig. 2.2). Secondary centers of osifcation appear inthe other cartilaginous epiphyses at varying ages after bith, Each such center, or one mt ‘leu, ssepuated from the metaphysis by a special plat of growing cardlage—the pip teal plate or ploy, which provides growth in the length ofthe bone through che interstitial srowth of cartilage cells “The short bones (the carpal bones) are developed by endochondral ossification in the same manner asthe epiphyses. By contrast, the lvl and mostof the sul develop bone directly the mesenchymal mode by the pro- cess ofimamembranous ossification from the Peron ito gga rows phase uring the earty week of intrauterine if, the developing embryo is paricularty suscep ble to notious environmental fcros that a= rive via the placental circulation. For example, ifthe mother develops a rubella infection oF takes a harmful drug sch as thalidomide dur- ing this ertcal period, embryonic develop- ments ikel to be seriously fected, The ex tent ofthe resultant abnormality depends on ‘Chapter 2. Normal Structure and Function of Musculoskeletal Tissues 11 liver. Thyroxine is also essential for normal longitudinal growth. Sex hormones are in- volved in the characteristic postpubertal “growth spurt” in adolescent boys and gies. Glucocorticoids (cortisones) have an inhibi tory effect on growth as seen in Cushing's syndrome, whether naturally occurring or secondary to prolonged therapeutic adminis: tration of cortisone to children Growth in Width Bones increase in width by means of apposi- tional growth from the osteablastsinthe deep, ‘or inner (cambium), layer of the periosteum, the process being one of intramembranous os. sification. Simultancously, the medullary c2v ity becomeslarger through osteoclastic resomp- tion of bone on the inner surface of the cortex, ‘which is lined by endosteum. Remodeling of Bone During longitudinal growth, the flared me- taphyseal regions of bone must be continually remodeled as the epiphysis moves progres- sively farther away from the shaft. This is ac: ‘complished by simultaneous osteoblastic dep: ‘sition of bone on one surface and osteoclastic internal architecture of the upper end of the femur (Fig. 2.6). cis likely thatthe phenomenon of Wolfs law is mediated by induced electrical poten- tials. For cxample, in a bowed tubular bone—or a curved tabecula of cancellous bbone—a negative electrical charge or poten: tial exists on the coneave side (compression force) and a postive charge on the convex side (tension force). Furthermore, it would seem that a negative charge induces bone deposi- tion, whereas a postive charge induces bone resorption. (During the past decade, this con ‘cept of electrical stimulation of osteogenesis has been increasingly applied to the healing Of delayed union of fractures in patients, as. discussed in Chapters 6 and 15} Anatomy and Histology of Bones as Structures Anatomical structure Bones, from the viewpoint of their gross struc- ture, are classified as 1) long bones, or tubular bones (e.g. femur), 2) short bones or cuboidal bones (eg. eapal bones), and 3) lat bones (€4&, scapula), Furthermore, cach bone con- ‘sition of bone on one ska ant OsteoeasHS resorption on the opposite surfie However, remodeling of bone continues throughout lie since some haversian systems, for exteons, continually erode through ll ‘death as well a through factors that demand removal of calcium from bone; therefore, dep ‘sition of bone must aso contne to main tain bone balance. During the growing years, bone deposition exceeds bone resorption, and the child is ina state of pastve bone balance By contrat in od age, bone deposition ean not keep pace with bone resorption, and the elderly person isin a state of negative bone balance Remodeling of bone also occurs in re- sponse to physical stresses—or to the lack of them—in that bone is deposited in sites sub jected to stres and is resorbed from sites ‘where there i ile stress. This phenomenon ‘generally referred to as Wolf law and is ‘exemplified by marked cortical thickening on the concave side ofa curved bone (Fig. 2.5) as ‘wells by the alignment of trabecular systems along the lines of weightbearing stress in the sists of dense cortical bone (compacta )on the ‘outside and a sponge-like arrangement of ra becular bone (spongiess) on the inside (Fig. 2.7). In children, the covering periosteum is thick and loosely attached to the cortex, and ic produces new bone readily. In adults, by contrast, the periosteum becomes progres- sively thinner and more adherent to the cor tex, and it produces new bone less readily. “This fandamental difference explains, in part, ‘why fractures heal more rapidly in young chil dren than in adults. Blood Supply to Long Bones Three distinct vascular systems exist in long bones: 1) an afferent vascular system compris ing nutrient and metaphyseal arteries that to: gether supply the inner two thirds ofthe cor: tex and periosteal arteries that supply. the ‘outer one third, 2 )an efferen vascular system that conveys venous blood, and 3) an ineerme- diate vascular system of capillaries within the cortex. The direction of blood flow through a long bone is normally centrifugal, that is, 12 Section! Basie Musculoskeletal Science gure 25, “Left An cxample of Wolf's Iw is sen inthe tibia of 2-year-old child with 1 Bow le defrmiy, Note the sgnifcant thickening ofthe medal cores, which onthe ‘Concave side ofthe deformity and is aubjested tothe most sex on wightheaing, Figure 2.6. Right. An cxample of Wolfs aw is sem in the itsral architecture ofthis ded specimen of the upper end ofthe femar of an adult Note the alignment of the teabeclar sytem of cancellous bone along th Eines of weight bearing secs, from the medullary cavity to the periosteal surface. Histological Structure From the viewpoint of its microscopic struc: ture, bone is classified in the following way (the’commonly used synonyms are included in parentheses) + Immature bone (nonlamellar bone, wowen bone, fiber bone) + Mature bone (lamellar bone): (1) cortical bone (dense bone, compacta); (2) cancel lous bone (trabecular bone, spongiosa) The two major histological types of bone demonstrate significant differences in their relative content of cells, collagen, and proteo: aycans Immature Bone The frst one that i formed by endochondral ‘ossification during embryonic development is Cf the immature type; subsequently, itis re placed gradually by mature bone s0 that by the age of 1 year, immature bone is no longer seen under normal conditions. Nevertheless, throughout life, under any abnormal condi- tion in which new bone is formed rapidly (such as the healing of fracture and the reac: tion toan infection or a tumor), the first bone formed is of the immature type. Here again, the rapidly formed immature bone is subse quently replaced by mature bone, Immature bone, aso called fiber bone or woven bone because ofits large proportion of iregularly “woven” collagen fibers in a haphazard ar- rangement, is very cellular and contains more [ec vercetunirSuostance;ienes ura icin 14 Section! Basic Musculoskeletal Science

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