Anterior View of the skeletal system Posterior View of the skeletal system

The Skeletal System serves many important functions; it provides the shape and
form for our bodies in addition to supporting, protecting, allowing bodily
movement, producing blood for the body, and storing minerals.

Functions

Its 206 bones form a rigid framework to which the softer tissues and organs of
the body are attached.

Vital organs are protected by the skeletal system. The brain is protected by the
surrounding skull as the heart and lungs are encased by the sternum and rib cage.

Bodily movement is carried out by the interaction of the muscular and skeletal
systems. For this reason, they are often grouped together as the musculo-skeletal
system. Muscles are connected to bones by tendons. Bones are connected to each
other by ligaments. Where bones meet one another is typically called a joint.
Muscles which cause movement of a joint are connected to two different bones
and contract to pull them together. An example would be the contraction of the
biceps and a relaxation of the triceps. This produces a bend at the elbow. The
contraction of the triceps and relaxation of the biceps produces the effect of
straightening the arm. Blood cells are produced by the marrow located in some
bones. An average of 2.6 million red blood cells are produced each second by the
bone marrow to replace those worn out and destroyed by the liver. Bones serve as
a storage area for minerals such as calcium and phosphorus. When an excess is
present in the blood, buildup will occur within the bones. When the supply of
these minerals within the blood is low, it will be withdrawn from the bones to
replenish the supply.
Types of Bone give the bone strength, and collagenous
fibers and ground substance to give the
The bones of the body fall into bone flexibility.
four general categories: long
bones, short bones, flat bones, Bone remodeling
and irregular bones. Long
bones are longer than they are Bone remodeling is a life long process
wide and work as levers. The where old bone is removed from the
bones of the upper and lower skeleton (a sub-process called bone
extremities (ex. humerus, tibia, resorption) and new bone is added (a sub-
femur, ulna, metacarpals, etc.) process called bone formation). These
are of this type. Short bones are processes also control the reshaping or
short, cube-shaped, and found replacement of bone during growth and
in the wrists and ankles. Flat following injuries. Remodeling responds
bones have broad surfaces for to functional demands and muscle
protection of organs and attachments. As a result bone is added
attachment of muscles (ex. ribs, where needed and removed where it is not
cranial bones, bones of required.
shoulder girdle). Irregular
bones are all others that do not In the first year of life, almost 100% of
fall into the previous the skeleton is replaced. In adults,
categories. They have varied remodeling proceeds at about 10% per
shapes, sizes, and surfaces year.
features and include the bones
of the vertebrae and a few in An imbalance in the regulation of bone
the skull. remodeling's two sub-processes, bone
resorption and bone formation, results in
Bone Composition many metabolic bone diseases, such as
osteoporosis.
Bones are composed of tissue
that may take one of two forms.
Compact, or dense bone, and
spongy, or cancellous, bone.
Most bones contain both types.
Compact bone is dense, hard,
and forms the protective
exterior portion of all bones.
Spongy bone is inside the
compact bone and is very
porous (full of tiny holes).
Spongy bone occurs in most
Bone Repair
bones. The bone tissue is
composed of several types of
bone cells embedded in a web
of inorganic salts (mostly
calcium and phosphorus) to
Skeletal Diseases
Growth & Developmental
Disorders
Gigantism - is abnormally
large growth due to an excess
of growth hormone during
childhood, before the bone
growth plates have closed.
Robert Wadlow at the middle w/
gigantism
Causes
The most common cause of too
much growth hormone release
is a non-cancerous (benign)
tumor of the pituitary gland.
Other causes include: Carney
complex, McCune-Albright
syndrome (MAS), Multiple
endocrine neoplasia type 1
(MEN-1), and
Neurofibromatosis.
Symptoms
The child will grow in height,
as well as in the muscles and
organs. This excessive growth
makes the child extremely
large for his or her age. Other
symptoms include: Delayed puberty,
Double vision or difficulty with side
(peripheral) vision, Frontal bossing and a
prominent jaw, Headache, Increased
sweating, Irregular periods
(menstruation), Large hands and feet with
thick fingers and toes, Release of breast
milk, Thickening of the facial features
and Weakness.
Diagnosis
• CT or MRI scan of the head
showing pituitary tumor
• Failure to suppress serum growth
hormone (GH) levels after an oral
glucose challenge (maximum 75g)
• High prolactin levels
• Increased insulin growth factor-I
(IGF-I) levels
Treatment
In pituitary tumors with well-defined
borders, surgery is the treatment of choice
and can cure many cases.
For situations in which surgery cannot
completely remove the tumor, medication
is the treatment of choice. The most
effective medications are somatostatin
analogs (such as octreotide or long-acting
lanreotide), which reduce growth
hormone release.
Dopamine agonists (bromocriptine
mesylate, cabergoline) have also been
used to reduce growth hormone secretion,
but these are generally less effective. A
medication that blocks the effect of
growth hormone, pegvisomant, has
recently become available.
Radiation therapy has also been used
to bring growth hormone levels to
normal. However, it can take 5-10 years
for the full effects to be seen and almost
always leads to low levels of other
pituitary hormones.
Most experts will use radiation only if
surgery and medication fail.
Dwarfism - refers to a
condition in individual plants
or animals characterized by
extreme small size. In older
popular and medical usage, any
type of marked human
smallness could also be termed
dwarfism. The term as related
to human beings (the major
subject of this article) is often
used to refer specifically to
those forms of extreme
shortness characterized by
disproportion of body parts,
typically due to an inheritable
disorder in bone or cartilage
development.
A 7 pounds girl at age of 2
Primordial Dwarfism.
Causes
Most dwarfism-related
conditions are genetic
disorders, but the causes of
some disorders are unknown.
Most occurrences of
dwarfism result from a random
genetic mutation in either the
father's sperm or the mother's
egg — rather than being in one
of the parent's complete genetic
makeup.
Diagnosis
Unusually short stature for a child's age is
usually what brings the child to medical
attention. Skeletal dysplasia ("dwarfism")
is usually suspected because of obvious
physical features (e.g., unusual
configuration of face or shape of skull),
because of an obviously affected parent,
or because body measurements (arm span,
upper to lower segment ratio) indicate
disproportion. Bone x-rays are often the
key to diagnosis of a specific skeletal
dysplasia, but they are not the key
diagnosis.
Treatments
Most dwarfism treatments don't increase
stature but may alleviate problems caused
by complications.
Common surgical treatments
Surgical procedures that may correct
problems with bones in people with
disproportionate dwarfism include:
• Inserting metal staples into the ends
of long bones where growth occurs
(growth plates) in order to correct
the direction in which bones are
growing
• Dividing a limb bone, straightening
it and inserting metal plates to hold
it in place
• Inserting rods or staples to help
correct the shape of the spine
• Increasing the size of the opening
in bones of the spine (vertebrae) to
alleviate pressure on the spinal cord
Rickets- is a softening of the • Dental deformities
bones in children potentially o Delayed formation of teeth
leading to fractures and o Defects in the structure of teeth,
deformity. Rickets is among the holes in the enamel
most frequent childhood o Increased incidence of cavities in
diseases in many developing the teeth (dental caries)
countries. o Progressive weakness
o Decreased muscle tone (loss of
Cause muscle strength)
The predominant cause is a
vitamin D deficiency, but lack Diagnosis
of adequate calcium in the diet A doctor may diagnose rickets by:
may also lead to rickets. • Blood tests:
Although it can occur in adults,
• Serum calcium may show low
the majority of cases occur in
levels of calcium, serum
children suffering from severe
phosphorus may be low, and serum
malnutrition, usually resulting
alkaline phosphatase may be high.
from famine or starvation
during the early stages of • Arterial blood gases may reveal
childhood. metabolic acidosis
• X-rays of affected bones may show
Symptoms: loss of calcium from bones or
changes in the shape or structure of
• Bone pain or the bones.
tenderness • Bone biopsy is rarely performed
o Arms but will confirm rickets.
o Legs
o Spine
o Pelvis
• Skeletal deformities
o Bowlegs
o Forward projection of
the breastbone (pigeon
chest)
o Bumps in the rib cage
(rachitic rosary)
o Asymmetrical or odd-
shaped skull
o Spine deformities Young child Legs X-ray w/ rickets
(spine curves
abnormally, including Treatment
scoliosis or kyphosis) The treatment and prevention of rickets is
o Pelvic deformities known as antirachitic.
• Increased tendency
toward bone fractures
Bacterial Infection
Osteomyelitis - is an
infection of bone or bone
marrow, usually caused by
pyogenic bacteria or
mycobacteria. It can be
usefully subclassified on the
basis of the causative organism,
the route, duration and
anatomic location of the
infection.
Causes
Staphylococcus aureus is the
organism most commonly
isolated from all forms of
osteomyelitis.
Symptoms
Signs and symptoms of
osteomyelitis depend on
whether the condition is acute,
lasting several months or less,
or chronic, lasting several
months to years.
Signs and symptoms of acute
osteomyelitis include:
• Fever that may be abrupt
• Irritability or lethargy in
young children
• Pain in the area of the
infection
• Swelling, warmth and
redness over the area of
the infection
Signs and symptoms of chronic
osteomyelitis include:
• Warmth, swelling and
redness over the area of
the infection
• Pain or tenderness in the
affected area
• Chronic fatigue
• Drainage from an open wound near
the area of the infection
• Fever, sometimes
Osteomyelitis of the tibia of a young child.
Numerous abscesses in the bone show as
radiolucency.
Diagnostic
The process of diagnosing a spinal
infection usually starts with an x-ray. X-
rays will usually be normal in the first 2
to 4 weeks after the infection starts. For
changes to show up on an x-ray, 50% to
60% of the bone in the vertebral body
needs to be destroyed. If the disc space is
involved (discitis), the disc space may
narrow and destruction of the endplates
around the disc may be seen on the x-ray.
The most sensitive and specific imaging
study for spinal infection is a MRI scan
with enhancement with an intravenous
dye (Gadolinium). The infection will
cause an increase in blood flow to the
vertebral body, and this will be picked up
by the Gadolinium, which will enhance
the MRI signal in areas of increased
blood flow.
 painless mass. Some bone tumors may
Treatment weaken the structure of the bone, causing
Osteomyelitis often requires pathologic fractures.
prolonged antibiotic therapy,
with a course lasting a matter
of weeks or-months. A PICC
line or central venous catheter
is often placed for this purpose.
Osteomyelitis also may require
surgical debridement. Severe
cases may lead to the loss of a
limb. Initial first line antibiotic
choice is determined by the
patient's history and regional
differences in common
infective organisms.

Tumors

Bone tumor - is an inexact

term, which can be used for
both benign and malignant
abnormal growths found in
bone, but is most commonly
used for primary tumors of
bone, such as osteosarcoma (or
osteoma). It is less exactly
applied to secondary, or
metastatic tumors found in
bone.
Causes
The cause of bone tumors is
unknown. They often arise in
areas of rapid growth. Possible
causes include:
• Inherited genetic
mutations
• Radiation
• Trauma
Symptoms
The most common symptom of
bone tumors is pain, but many
patients will not experience any
symptoms, except for a
Thighbone (femur) tumor. The X-ray shows a
bone tumor in the middle of the thighbone.
The tumor is also seen using magnetic
resonance imaging (MRI). The insert at the
top shows a coronal MRI. The insert at the
bottom shows a cross sectional MRI. The
arrows on all images show the location of the
tumor.
Diagnosis
The doctor will collect detailed
information about general health and the
tumor's type, size, location, and possible
extent of spread.
Medical History-
The doctor will need to take a complete
medical history. This includes learning
about any medications you take, details
about any previous tumors or cancers that
you or your family members may have
had, and symptoms you are experiencing.
Physical Examination-
Your doctor will physically examine you.
The focus is on the tumor mass,
tenderness in bone, and any impact on
joints and/or range of motion. In some
cases, the doctor may want to
examine other parts of your
body to rule out cancers that
can spread to bone.
Imaging-
Your doctor will probably
obtain X-rays. Different types
of tumors have different
characteristics on X-ray.
Treatment
Treatment of bone tumors is
highly dependent on the type of
tumor.
Decalcification
Osteomalacia - is the
general term for the softening
of the bones due to defective
bone mineralization.
Osteomalacia in children is
known as rickets, and because
of this, osteomalacia is often
restricted to the milder, adult
form of the disease. It may
show signs as diffuse body
pains, muscle weakness, and
fragility of the bones.
Cause
The causes of adult
osteomalacia are varied.
• Insufficient sunlight
exposure, especially in
dark-skinned subjects
• Insufficient nutritional
quantities or faulty
metabolism of vitamin
D or phosphorus
• Renal tubular acidosis
• Malnutrition during
pregnancy
• Malabsorption
syndrome
• Chronic renal failure
• Therapy with Fumaderm
Symptoms
In the early stages, you may have no
osteomalacia symptoms, although signs
of osteomalacia may be apparent on X-
ray pictures or other diagnostic tests. As
osteomalacia worsens, symptoms may
include:
• Bone pain. People with
osteomalacia often experience pain
in their bones, especially in the
lower spine, pelvis and legs and
feet. Pain associated with
osteomalacia is usually dull and
aching and worsens during physical
activity. You might notice that
gently pressing on a bone — on
your shin, for example — produces
severe pain.
• Muscle weakness. Osteomalacia
can cause weakness or stiffness in
your arms and legs, decreased
muscle tone and discomfort while
moving. Some people with
osteomalacia walk with a waddling
motion.
A young male with osteomalacia. Note a
pseudofracture in the medial edge of the upper
femoral shaft (arrow).

Diagnosis
To make a diagnosis of
osteomalacia, your doctor will
likely ask you about your
symptoms, the amount of time
that you spend in the sun and
your diet. In order to rule out
other bone disorders, such as
osteoporosis, you may undergo
one or more of the following
tests:
• Blood and urine tests. In
cases of osteomalacia
caused by vitamin D
deficiency or by
phosphorus loss,
abnormal levels of
vitamin D and the
minerals calcium and
phosphorus are often
detected.
• X-ray. Slight cracks in
your bones that are
visible on X-rays,
referred to as Looser
transformation zones, are
a characteristic feature of
people with
osteomalacia.
• Bone scan. This
procedure detects areas
of increased and
decreased bone
metabolism in your body.
During this test, a
radioactive dye is
injected into a vein and a
camera takes pictures of
how much radioactive
dye collects in your
bones. If you have
osteomalacia, the
radioactive dye may
appear to be unevenly distributed in
some areas of your bones.
• Bone biopsy. During a bone biopsy,
your doctor inserts a slender needle
through your skin and into your
bone to withdraw a small sample
for viewing under a microscope.
Although a bone biopsy is very
accurate in detecting osteomalacia,
it's not often needed to make the
diagnosis.
Treatment
Nutritional osteomalacia responds well to
administration of 200,000 IU weekly of
vitamin D for 4 to 6 weeks, followed by a
maintenance dose of 1600 IU daily or
200,000 IU every 4 to 6 months.
Osteoporosis - is a disease of bone that
leads to an increased risk of fracture. In
osteoporosis the bone mineral density
(BMD) is reduced, bone
microarchitecture is disrupted, and the
amount and variety of non-collagenous
proteins in bone is altered.
Cause
There is no single cause of osteoporosis.
Our bodies constantly build new bone and
remove older bone. In childhood, more
bone is built than removed, and so the
bones grow in size. After age 30 or 40,
however, the cells that build new bone do
not keep up with those that remove bone.
The total amount of bone then decreases,
and osteoporosis may develop as a result.
Symptoms
Osteoporosis itself has no specific
symptoms; its main consequence is the
increased risk of bone fractures.
Osteoporotic fractures are those that
occur in situations where healthy people
would not normally break a bone; they
are therefore regarded as fragility
fractures. Typical fragility
fractures occur in the vertebral
column, rib, hip and wrist.
X- ray lateral view of Vertebrae
Diagnosis
Osteoporosis is a condition of
low bone density that can
progress silently over a long
period of time. If diagnosed
early, the fractures associated
with the disease can often be
prevented. Unfortunately,
osteoporosis frequently
remains undiagnosed until a
fracture occurs.
An examination to diagnose
osteoporosis can involve
several steps that predict your
chances of future fracture,
diagnose osteoporosis, or both.
It might include:
• an initial physical exam
• various x rays that detect
skeletal problems
• laboratory tests that
reveal important
information about the
metabolic process of
bone breakdown and
formation
• a bone density test to detect low
bone density.
Before performing any tests, your doctor
will record information about your
medical history and lifestyle and will ask
questions related to:
• risk factors, including information
about any fractures you have had
• your family history of disease,
including osteoporosis
• medication history
• general intake of calcium and
vitamin D
• exercise pattern
• for women, menstrual history.
In addition, the doctor will note medical
problems and medications you may be
taking that can contribute to bone loss
(including glucocorticoids, such as
cortisone). He or she will also check your
height for changes and your posture to
note any curvature of the spine from
vertebral fractures, which is known as
kyphosis.
Treatment
The primary goal of treatment of
osteoporosis is to reduce the risk of
pathologic fractures. The three mainstays
of treatment are:
• Weight-bearing exercise
• Nutrition supplementation
• Medications
 Bone Fractures

Fractures
A fracture is commonly referred to as a broken bone. Fractures are common; the
average person has two during a lifetime. They occur when the physical force
exerted on the bone is stronger than the bone itself. Your risk of fracture depends,
in part, on your age. Broken bones are very common in childhood, though
children's fractures are generally less complicated than fractures in adults. Older
people, whose bones are more brittle, are more likely to suffer fractures from
falls that would not affect younger people.

There are many types of fractures, but the main categories are complete,
incomplete, compound and simple. Complete and incomplete fractures refer to
the way the bone breaks: In a complete fracture, the bone snaps into two or more
parts; in an incomplete fracture, the bone cracks but does not break all the way
through. In a compound fracture, also called an open fracture, the bone breaks
through the skin; it may then recede back into the wound and not be visible
through the skin. In a simple fracture, also called a closed fracture, the bone
breaks but there is no open wound in the skin.
Simple fractures include:

Comminuted fracture
Greenstick Fracture.
Comminuted fracture: a fracture in
Greenstick fracture: an which the bone fragments into several
incomplete fracture in which pieces.
the bone is bent. This type
occurs most often in children.

Transverse fracture

Transverse fracture: a
fracture at a right angle to the Buckle fracture of the distal radius. Arrows indicate
location of fracture.
bone's axis.
Impacted fracture: is one whose ends
are driven into each other. This is
commonly seen in arm fractures in
children and is sometimes known as a
buckle fracture. Other types of fracture
Oblique fracture are pathologic fracture, caused by a
disease that weakens the bones, and stress
Oblique fracture: a fracture in fracture, a hairline crack.
which the break slopes.
Other types of fracture: are pathologic
fracture, caused by a disease that weakens
the bones, and stress fracture, a hairline
crack.
Joint
A joint is the location at which two or
more bones make contact. They are
constructed to allow movement and
provide mechanical support, and are
classified structurally and functionally.

Classification
Joints are mainly classified structurally
and functionally. Structural classification
is determined by how the bones connect
to each other, while functional
classification is determined by the
degree of movement between the
articulating bones. In practice, there is
significant overlap between the seven types of classifications.
Terms ending in the suffix -sis are singular and refer to just one joint, while -ses
is the suffix for pluralization.

Structural classification Most synarthrosis joints are fibrous

Structural classification names
and divides joints according to
how the bones are connected to
each other. There are three
structural classifications of
joints:
• fibrous joint - joined by
fibrous connective tissue
• cartilaginous joint -
joined by cartilage
• synovial joint - not
directly joined
joints (eg The Skull).
• amphiarthrosis - permits slight
mobility. Most amphiarthrosis
joints are cartilaginous joints (eg.
Vertabrae).
• diarthrosis - permits a variety of
movements. All diarthrosis joints
are synovial joints (eg. Shoulder,
Hip, Elbow, Knee etc), and the
terms "diarthrosis" and "synovial
joint" are considered equivalent by
Terminologia Anatomica.

Functional classification
Joints can also be classified
functionally, by the degree of
mobility they allow:

• synarthrosis - permits
little or no mobility.
Joint Disorders weight can lead to arthritis. This is
especially true of the hips and knees that
Arthritis can be worn quickly in heavier patients.

Previous Injury
Arthritis (from Greek arthro-,
joint + -itis, inflammation;
Joint damage can cause irregularities in
plural: arthritides) is a group of
the normal smooth joint surface. Previous
conditions involving damage to
major injuries can be part of the cause of
the joints of the body. Arthritis
arthritis. An example of an injury leading
is the leading cause of
to arthritis is a tibial plateau fracture,
disability in people older than
where the broken area of bone enters the
fifty-five years.
cartilage of the knee joint.
Cause
Occupational Hazards
Determining the cause of
arthritis can be difficult,
Workers in some specific occupations
because often several factors
seem to have a higher risk of developing
contribute to an individual
arthritis than other jobs. These are
developing this common
primarily high demand jobs such as
problem. Some of the risk
assembly line workers and heavy
factors that can cause arthritis
construction.
include:
Some High-Level Sports
Genetics
It is difficult to determine how much
Exactly how much heredity or
sports participation contributes to
genetics contributes to the
development of arthritis. Certainly, sports
cause of arthritis is not well
participation can lead to joint injury and
understood. However, there are
subsequent arthritis. However, the
likely genetic variations that
benefits of activity likely outweigh any
can contribute to the cause of
risk of arthritis.
arthritis.
Illness or Infection
Age
People who experience a joint infection
Cartilage becomes more brittle
(septic joint), multiple episodes of gout,
with age and has less of a
or other medical conditions, can develop
capacity to repair itself. As
arthritis of the joint.
people grow older they are
more likely to develop arthritis.
Symptoms
Joint pain and progressive stiffness
Weight
without noticeable swelling, chills, or
fever during normal activities probably
Because joint damage is partly
indicate the gradual onset of
dependent on the load the joint
osteoarthritis.
has to support, excess body
Diagnosis
Arthritis diagnosis information,
blood tests, and other
diagnostic tests. Physical
examination and diagnostic
tests, along with a patient's
clinical picture, help to
formulate an accurate
diagnosis.
Arthrography - is an imaging
technique that utilizes contrast
dye so that certain structures of
the joints that aren't readily
seen on traditional X-rays can
be seen. Arthrography helps
detect joint damage and
problems with surrounding
structures.
Arthritis is a complicated
disease with many different
types. To accurately diagnose
arthritis, a medical history,
physical examination,
laboratory tests, and medical
imaging are involved.
Patient hands X-ray-Arthritis
Treatment
Treatment options vary
depending on the type of
arthritis and include physical
and occupational therapy,
lifestyle changes (including
exercise and weight control),
medications and dietary
supplements (symptomatic or
targeted at the disease process causing the
arthritis). Arthroplasty (joint replacement
surgery) may be required in eroding
forms of arthritis.
In general, studies have shown that
physical exercising of the affected joint
can have noticeable improvement in
terms of long-term pain relief.
Furthermore, exercising of the arthritic
joint is encouraged to maintain the health
of the particular joint and the overall body
of the person.
Another form of non-drug treatment that
does have a body of proper research to
support its efficacy is marine oil, from
both fish and the New Zealand green-
lipped mussel (Perna canaliculus). Diets
high in marine oils from cold-water fish
such as salmon, mackerel, and tuna have
been shown to reduce the inflammation of
joint conditions such as arthritis. Massage
on joints with neem oil has reported
improvement in chronic and acute cases
Rheumatoid arthritis (RA) is a
chronic, systemic autoimmune disorder
that causes the immune system to attack
the joints, where it causes inflammation
(arthritis) and destruction. It can also
damage some organs, such as the lungs
and skin. It can be a disabling and painful
condition, which can lead to substantial
loss of functioning and mobility.
Cause
The cause of rheumatoid arthritis is a very
active area of worldwide research. Some
scientists believe that the tendency to
develop rheumatoid arthritis may be
genetically inherited. It is suspected that
certain infections or factors in the
environment might trigger the immune
system to attack the body's own tissues,
resulting in inflammation in various
organs of the body such as the lungs or
eyes.
Regardless of the exact
trigger, the result is an
immune system that is geared
up to promote inflammation in
the joints and occasionally
other tissues of the body.
Immune cells, called
lymphocytes, are activated and
chemical messengers
(cytokines, such as tumor
necrosis factor/TNF and
interleukin-1/IL-1) are
expressed in the inflamed
areas.
Environmental factors also
seem to play some role in
causing rheumatoid arthritis.
Recently, scientists have
reported that smoking tobacco
increases the risk of
developing rheumatoid
arthritis.
Symptoms
While rheumatoid arthritis
primarily affects joints,
problems involving all other
organs of the body are known
to occur. Extra-articular
("outside the joints")
manifestations occur in about
15% of individuals with
rheumatoid arthritis. It can be
difficult to determine whether
disease manifestations are
directly caused by the
rheumatoid process itself, or
from side effects of the
medications commonly used to
treat it - for example, lung
fibrosis from methotrexate, or
osteoporosis from
corticosteroids.
Diagnosis
It is diagnosed with blood tests
(especially a test called rheumatoid
factor) and X-rays. Diagnosis and long-
term management are typically performed
by a rheumatologist, an expert in the
diseases of joints and connective tissues.
If one metacarpal phalangeal joint (MCP) is involved with
rheumatoid arthritis, then typically all of the joints are
involved. In this image we see that every MCP joint is affected.
The DIP (distal interphalangeal) joints are relatively spared.
This patient has also developed ligamentous abnormalities due
to RA. A radial deviation of the carpus and ulnar deviation of
the digits give the hands a characteristic zig-zag pattern.
Treatment
There is no known cure for rheumatoid
arthritis, but many different types of
treatment can alleviate symptoms and/or
modify the disease process.
The goal of treatment is two-fold:
alleviating the current symptoms, and
preventing the future destruction of the
joints with the resulting handicap if the
disease is left unchecked. These two goals
may not always coincide: while pain
relievers may achieve the first goal, they
do not have any impact on the long-term
consequences. For these reasons, most
authorities believe that most RA should
be treated by at least one specific anti-
rheumatic medication, also named
DMARD
(Disease modifying anti-rheumatic drugs)
reduces the rate of damage to bone and
cartilage.
Degenerative Joint Disease
Osteoarthritis (OA, also
known as degenerative
arthritis, degenerative joint
disease), is a clinical syndrome
in which low-grade
inflammation results in pain in
the joints, caused by abnormal
wearing of the cartilage that
covers and acts as a cushion
inside joints and destruction or
decrease of synovial fluid that
lubricates those joints. As the
bone surfaces become less well
protected by cartilage, the
patient experiences pain upon
weight bearing, including
walking and standing. Due to
decreased movement because
of the pain, regional muscles
may atrophy, and ligaments
may become more lax. OA is
the most common form of
arthritis and the leading cause
of chronic disability in the
United States. Osteoarthritis" is
derived from the Greek word
"osteo", meaning "of the bone",
"arthro", meaning "joint", and
"itis", meaning inflammation,
although many sufferers have
little or no inflammation.
Causes
Although it commonly arises
from trauma, osteoarthritis
often affects multiple members
of the same family, suggesting
that there is hereditary
susceptibility to this condition.
A number of studies have
shown that there is a greater
prevalence of the disease
between siblings and especially
identical twins, indicating a
hereditary basis. Up to 60% of OA cases
are thought to result from genetic factors.
Researchers are also investigating the
possibility of allergies, infections, or
fungi as a cause. There is some evidence
that allergies, whether fungal, infectious
or systemically induced, may be a
significant contributing factor to the
appearance of osteoarthritis in a synovial
sac. In osteoarthritis, the joint cartilage
breaks down. Cartilage exists within the
incudomalleolar and incudostapedial
joints. In addition, the cartilage-covered
base of the stapes footplate is bound to
the cartilage-covered rim of the oval
window by the annular ligament. Thus,
higher prevalence of middle ear
abnormalities and hearing loss can be
expected in osteoarthritis due to
degeneration of the cartilage and the
subsequent abnormal repair response.
Osteoarthritis and hearing loss are
considered among the top chronic health
concerns in older individuals although the
connection between these two conditions
has not been previously reported.
Primary
This type of OA is a chronic degenerative
disorder related to but not caused by
aging, as there are people well into their
nineties who have no clinical or
functional signs of the disease.
Secondary
This type of OA is caused by other factors
or diseases but the resulting pathology is
the same as for primary OA: Congenital
disorders, such as: Congenital hip
luxation, Cracking joints, Diabetes,
Obesity and Hormonal disorders

Knee X-ray of a person w/ Osteoarthritis.
Diagnosis
Diagnosis is normally done
through x-rays. This is possible
because loss of cartilage,
subchondral
("below cartilage") sclerosis,
subchondral cysts from
synovial fluid entering small
microfractures under
pressure, narrowing of the joint
space between the articulating
bones, and bone spur formation
(osteophytes) - from increased
bone turnover in this
inflammatory
condition, show up clearly on
x-rays. Plain films, however,
often do not correlate well with
the findings of physical
examination of the affected
joints.
With or without other
techniques, such as MRI
(magnetic resonance imaging),
arthrocentesis and arthroscopy,
diagnosis can be made by a
careful study of the duration, location, the
character of the joint symptoms, and the
appearance of the joints themselves. As
yet, there are no methods available to
detect OA in its early and potentially
treatable stages.
Treatment
Generally speaking, the process of
clinically detectable osteoarthritis is
irreversible, and typical treatment consists
of medication or other interventions that
can reduce the pain of OA and thereby
improve the function of the joint.
Conservative care
No matter the severity or location of OA,
conservative measures such as weight
control, appropriate rest and exercise, and
the use of mechanical support devices are
usually beneficial. In OA of the knees,
knee braces, a cane, or a walker can be
helpful for walking and support. Regular
exercise, if possible, in the form of
walking or swimming, is encouraged.
Applying local heat before, and cold
packs after exercise, can help relieve pain
and inflammation, as can relaxation
techniques. Heat - often moist heat -eases
inflammation and swelling, and may
improve circulation, which has a healing
effect on the local area. Weight loss can
relieve joint stress and may delay
progression. Proper advice and guidance
by a health care provider is important in
OA management, enabling people with
this condition to improve their quality of
life.
Medical treatment
Medical treatment includes NSAIDs,
local injections of glucocorticoid or
hyaluronan, and in severe cases, with
joint replacement surgery. There has been
no cure for OA, as cartilage has
not been induced to regenerate.
However, if OA is caused by
cartilage damage (for example
as a result of an injury)
Autologous Chondrocyte
Implantation may be a possible
treatment. Clinical trials
employing tissue-engineering
methods have demonstrated
regeneration of cartilage in
damaged knees, including
those that had progressed to
osteoarthritis. Further, in
January 2007, Johns Hopkins
University was offering to
license a technology of this
kind, listing several clinical
competitors in its market
analysis.
Dietary
Supplements which may be
useful for treating OA include:
Glucosamine -A molecule
derived from glucosamine is
used by the body to make some
of the components of cartilage
and synovial fluid.
Supplemental glucosamine
may improve symptoms of OA
and delay its progression.
Chondroitin -Along with
glucosamine, chondroitin
sulfate has become a widely
used dietary supplement for
treatment of osteoarthritis. A
meta-analysis of randomized
controlled trials found no
benefit from chondroitin.
Gout
Gout (also called metabolic arthritis) is a
disease created by a buildup of uric acid.
In this condition, monosodium urate or
uric acid crystals are deposited on the
articular cartilage of joints, tendons and
surrounding tissues due to elevated
concentrations of uric acid in the
bloodstream. This provokes an
inflammatory reaction of these tissues.
Cause
Gout is caused by too much uric acid in
the blood (hyperuricemia). Hyperuricemia
usually does no harm, and most people
with high levels of uric acid in the blood
never develop gout. The exact cause of
hyperuricemia sometimes goes
undiscovered, although inherited factors
(genes) seem to play a role. When uric
acid levels in the blood are too high, uric
acid may form crystals that accumulate in
the joints.
Symptoms
Gout is characterized by excruciating,
sudden, unexpected, burning pain, as well
as swelling, redness, warmth, and
stiffness in the affected joint. This occurs
commonly in men in their toes but can
appear in other parts of the body and
affects women as well. Low-grade fever
may also be present. The patient usually
suffers from two sources of pain. The
crystals inside the joint cause intense pain
whenever the affected area is moved. The
inflammation of the tissues around the
joint also causes the skin to be swollen,
tender and sore if it is even slightly
touched. For example, a blanket or even
the lightest sheet draping over the
affected area could cause extreme pain.
Gout usually attacks the big toe
(approximately 75 percent of first
attacks); however, it also can affect other
joints such as the ankle, heel,
instep, knee, wrist, elbow,
fingers, and spine. In some
cases, the condition may appear
in the joints of small toes that
have become immobile due to
impact injury earlier in life,
causing poor blood circulation
that leads to gout.
Arthrocentesis: A more reliable method of
diagnosis uses arthrocentesis. Using a
syringe and needle a synovial fluid
sample is taken from an affected joint.
The synovial fluid is analysed under a
microscope. The presence of monosodium
urate (MSU) crystals in the fluid indicates
the presence of gout.

Diagnosis

Physical examination and

review of medical history:
Diagnosis usually begins
with a review of family
medical history and a physical
examination. The presence of
tophi below the skin and red
shiny skin above the affected
area can indicate gout.
However a more thorough
medical examination is
required to eliminate the other
conditions listed above.

Blood test: A blood test can be

used to measure levels of uric
acid in the blood. This is not a
reliable method for diagnosing
gout. During a gout attack
Showing multiple erosion locations including first MTP,
blood uric acid levels can lie base of third and fourth metacarpals, and possibly the
within the normal range. Also, head of the fifth metacarpal and second proximal
high uric acid levels don't phalanx.
always indicate the presence of
gout. Treatment

X-rays: X-rays can be taken to Acute attacks

show tophi crystals around the
joints and under the skin.
However, X-rays of affected
joints often show the joints to
be normal so may not help in
the diagnosis.
The first line of treatment should be pain
relief. Once the diagnosis has been
confirmed, the drugs of choice are
indomethacin, other nonsteroidal anti-
inflammatory drugs (NSAIDs), oral
glucocorticoids, or intra-articular
glucocorticoids administered via a joint
injection.
Colchicine was previously the
drug of choice in acute attacks
of gout, as it impairs the
motility of granulocytes and
can prevent the inflammatory
phenomena that initiate an
attack. Colchicine should be
taken within the first 12 hours
of the attack and usually
relieves the pain within 48
hours, although side effects
(gastrointestinal upset such as
diarrhea and nausea) can
complicate its use. NSAIDs are
the preferred form of analgesia
for patients with gout.
A randomized controlled trial
found similar benefit from
nonsteroidal anti-inflammatory
drugs and oral glucocorticoids;
however, less adverse drug
reactions occurred in the
glucocorticoids group. In the
nonsteroidal anti-inflammatory
drugs group, each patient
initially received diclofenac (75
mg) intramuscularly,
indomethacin 50 mg orally, and
acetaminophen 1 g orally. The
patient was received a 5-days
of indomethacin (50 mg orally
every 8 hours for 2 days,
followed by indomethacin 25
mg every 8 hours for 3 days),
and acetaminophen 1 g every 6
hours as needed. The
glucocorticoids patients
received prednisolone 30 mg
orally, and acetaminophen 1 g
orally. The patient was then
given prednisolone 30 mg
orally once per day for five
days.
Chronic joint changes
For extreme cases of gout, surgery may
be necessary to remove large tophi and
correct joint deformity.
Bursitis and Bunions
Bursitis is the inflammation of one or
more bursae (small sacs) of synovial fluid
in the body. The bursae rest at the points
where internal functionaries, such as
muscles and tendons, slide across bone.
Healthy bursae create a smooth, almost
frictionless functional gliding surface
making normal movement painless. When
bursitis occurs, however, movement
relying upon the inflamed bursa becomes
difficult and painful. Moreover,
movement of tendons and muscles over
the inflamed bursa aggravates its
inflammation, perpetuating the problem.
Causes
Bursitis is commonly caused by repetitive
movement and excessive pressure.
Elbows and knees are the most commonly
affected. Inflammation of the bursae
might also cause other inflammatory
conditions such as rheumatoid arthritis.
Although infrequent, scoliosis might
cause bursitis of the shoulders, however,
shoulder bursitis is more commonly
caused by overuse of the shoulder joint
and related muscles.
Traumatic injury is another cause of
bursitis. The inflammation irritates
because the bursa no longer fits in the
original small area between the bone and
the functionary muscle or tendon. When
the bone increases pressure upon the
bursa, bursitis results.
Symptoms
Bursitis symptoms vary from
local joint pain and stiffness, to
burning pain that surrounds the
joint around the inflamed
bursa. In this condition, the
pain usually is worse during
and after activity, and then the
bursa and the surrounding joint
become stiff the next day in the
morning.
Diagnosis
Bursitis is typically identified
by localized pain or swelling,
tenderness, and pain with
motion of the tissues in the
affected area. X-ray testing can
sometime detect calcifications
in the bursa when bursitis has
been chronic or recurrent.
Radiograph of Elbow w/ Bursitis
Treatment
The treatment of any form of
bursitis depends on whether or
not it involves infection.
Bursitis that is not infected
(from injury or underlying
rheumatic disease) can be
treated with ice compresses,
rest, and antiinflammatory and
pain medications. Occasionally,
it requires aspiration of the bursa fluid.
This procedure involves removal of the
fluid with a needle and syringe under
sterile conditions. It can be performed in
the doctor's office. Sometimes the fluid is
sent to the laboratory for further analysis.
Noninfectious bursitis can also be treated
with a cortisone injection into the swollen
bursa. This is sometimes done at the same
time as the aspiration procedure and
typically rapidly reduces the
inflammation of the swollen bursa.
Infectious (septic) bursitis requires even
further evaluation and aggressive
treatment. The bursal fluid can be
examined in the laboratory to identify the
microbes causing the infection. Septic
bursitis requires antibiotic therapy,
sometimes intravenously. Repeated
aspiration of the infected fluid may be
required. Surgical drainage and removal
of the infected bursa sac (bursectomy)
may also be necessary. Generally, the
adjacent joint functions normally after the
surgical wound heals.
Bunion (hallux valgus) is a structural
deformity of the bones and the joint
between the foot and big toe, and may be
painful.
Causes
People with certain foot types are more
likely to develop bunions. If you have flat
feet, or low arches, your chance of getting
bunions is increased.
Most bunions develop as a result of
wearing shoes that do not fit properly.
Women get bunions more often than men
because they tend to wear tight, pointed,
or high-heeled shoes. High heels push
most of your body weight onto the front
of your foot, placing a great strain on the
toe joints. Women also tend to have
looser ligaments than men, which make
them more prone to getting family has had bunions, or if you have
bunions. injured your foot in any way.
If your shoes are tight, they
will rub against the big toe An X-ray may sometimes be necessary to
joint. This can thicken the skin see how severe the bunion is and to check
and tissues and form a bunion. the alignment of your toes.
Continuing to wear badly
fitting shoes will make your
bunions worse.
Bunions can also be caused, or
made worse, by arthritis.
Arthritis is a condition where
the protective cartilage
covering the joints becomes
diseased or damaged. As the
joints are stiff, and hard to
move, it can be difficult to
straighten out your toes to
prevent them rubbing against
your shoes.

Symptoms
The symptoms of bunions
include irritated skin around Hallux valgus .
the bunion, joint redness and
pain, and possible shift of the Treatment
big toe toward the other toes. Bunions may be treated conservatively
with changes in shoe gear, different
Diagnosis orthotics (accommodative padding and
Bunions cause a visible shielding), rest, ice, and medications.
swelling at the base of the big These sorts of treatments address
toe. Your GP will therefore be symptoms more than they correct the
able to identify a bunion just by actual deformity. Surgery, by a Podiatrist,
looking at your foot. You may may be necessary if discomfort is severe
be asked to move your big toe enough or when correction of the
up and down to see if your deformity is desired.
range of movement is limited.
Your GP will also check for
redness and swelling and ask
you about pain.
You may also be asked about
the types of shoes that you
wear and how frequently you
wear them. You should tell
your GP if anyone in your
Divisions of the Skeleton

The human skeleton is divided into two distinct parts:

The axial skeleton consists of bones that form the axis of the body and support
and protect the organs of the head, neck, and trunk.

• The Skull
• The Sternum
• The Ribs
• The Vertebral Column

SKULL

Frontal view.
 Side view.

The skull
is the bony framework of the head. It is comprised of the eight cranial and
fourteen facial bones.

Cranial Bones

The cranial bones makeup the

protective frame of bone
around the brain.
The cranial bones are:

• The frontal forms part • cranium as well as housing

of the cranial cavity as
well as the forehead, the
brow ridges and the
nasal cavity.
• The left and right
parietal forms much of
the superior and lateral
portions of the cranium.
• The left and right
temporal form the
lateral walls of the
the external ear.
• The occipital forms the posterior
and inferior
• portions of the cranium. Many
neck muscles attach here as this is
the point of articulation with the
neck.
• The sphenoid forms part of the
eye orbit and helps to form the
floor of the cranium.
 • The ethmoid forms the orbits and the roof of the nasal
medial portions of the cavity.

The joints between bones of the the posterior portion of the roof of
skull are immovable and called the mouth.
sutures. The parietal bones are • The left and right zygomatic are
joined by the sagittal suture. the cheek bones. They form
Where the parietal bones meet portions of the orbits as well.
the frontal is referred to as the • The left and right nasal form the
coronal suture. The parietals superior portion of the bridge of
and the occipital meet at the the nose.
lambdoidal suture. The suture • The left and right lacrimal help to
between the parietals and the form the orbits.
temporal bone is referred to as
• The vomer forms part of the nasal
the squamous suture. These
septum (the divider between the
sites are the common location
nostrils).
of fontanelles or "soft spots"
The left and right inferior turbinate
on a baby’s head.
forms the lateral walls of the nose and
increase the surface area of the nasal
Facial Bones
cavity.
The facial bones makeup the
upper and lower jaw and other
facial structures.

The facial bones are:

• The mandible is the

lower jawbone. It
articulates with the
temporal bones at the
• temporomandibular
joints. This forms the
only freely moveable
joint in the head. It
provides the chewing
• motion.
• The left and right
maxilla are the upper
jaw bones. They form
part of the nose, orbits,
and roof of the mouth.
• The left and right
palatine form a portion
of the nasal cavity and
Feature Location Description
Angle of jaw or mandible back of jaw the corner of the jaw where the
mandible body turns upwards into
the ramus.
Aveolar process maxilla, root of teeth rugosities associated with tooth
development.
Condyle of mandible top of ramus of mandible a ball-like end to the ramus of the
mandible that forms a hinge with
the temporal bone.
Coronal suture top of head between one of the major joints or sutures
frontal and parietal between the plates of the frontal and
cranial bones parietal cranial bones.
External acoustic meatus between ramus of a hole in the temporal cranial bone
mandible and mastoid allowing the passage of sound to
process enter the inner ear.
Ethmoid bone eye cavity a cranial bone forming part of the
eye cavity.
Forehead boss or frontal forehead a feature of the frontal bone that
tuberosity forms the "bumps" in the forehead
above the eyebrows.
Grontal bone top of face (forehead) one of the major cranial bones that
and front top of head forms the forehead and front top of
the head; roughly covers the frontal
lobes of the brain.
Glabella center of forehead an area in the center of the forehead,
between the eyebrows, that assumes
various shapes on different
individuals.
Lacrimal bone inner corner of eye a small bone forming a cavity for
socket the tear gland.
Lambdoid suture back of head suture or joint between the occipital
and parietal cranial bones.
Mandible or jaw bone lower part of jaw the lower jaw bone is the only skull
bone that moves, i.e., during
mastication, speech, and expression;
carries the lower teeth.
Maxilla upper part of jaw the two maxillae form the center of
the face with many attaching
muscles; carry the upper teeth; form
part of the eye orbit; act like
keystones into which the other
facial bones fit.
Mastoid process lower part of temporal built up area of the lower temporal
bone, behind ramus of bone where important neck muscles
jaw attach.
Feature Location Description
Mental protuberance chin boss a feature of the mandible at the lower
front part of the chin which underlies
part of the chin boss.
Mental tuberosities chin boss a dual bulbous formation of the
mandible that underlies part of the chin
boss.
Nasal bone nose forms the upper part of the nose and
nasal bridge; the lower part of the bridge
is formed of cartilage.
Nasal concha nasal cavity Formations creating part of the nasal
cavity.
Nasal spine center of nose feature of maxilla facial bone at center
of nose to which septum is attached.
Occipital bone the lower rear of the a major cranial bone at the lower back
head of the head; covers occipital lobe of the
brain.
Parietal bone top and side of head a major cranial bone that froms part of
the top, back, and side of the head and
roughly covers the parietal lobe of the
brain.
Ramus of mandible back part of the the more vertical part of the mandible.
mandible
Sphenoid bone temple and eye orbit a cranial bone that forms part of the eye
area cavity.
Squamosal suture side of head between one of the major joints or sutures
parietal and temporal between the parietal and temporal
bones cranial bones.
Supraorbial foramen upper orbit of eye a hole in the frontal bone where nerves
and blood vessels pass through; forms a
notch in the orbit of the eye.
Supraorbital process eyebrows a formation of the frontal bone above
the orbit of the eye, under and above the
eyebrows that affects the appearance of
the eyebrows.
Temporal bone side of the head, above a cranial bone on the side of the head
the ear that roughly covers the temporal lobe of
the brain; it extends down behind the ear
towards the jaw.
Temporal lines front part of temple lines in the frontal bone around the
and lower part of temple.
frontal bones
Volmer nasal cavity a facial bone on the centerline of the
nose that forms part of the nasal cavity.

Zygomatic bone cheek the principal cheek bone; origin of

zygomatic and other facial muscles.

Zygomatic process bones bordering the temporal and maxilla bones have
zygomatic bone areas next to the zygomatic bone.
The Sternum
The sternum is a flat, dagger
shaped bone located in the
middle of the chest. Along with
the ribs, the sternum forms the
rib cage that protects the heart,
lungs, and major blood vessels
from damage.
The sternum is composed of
three parts:
The manubrim, also called the
"handle", is located at the top
of the sternum and moves
slightly. It is connected to the
first two ribs.
The body, also called the
"blade" or the "gladiolus", is
located in the middle of the
sternum and connects the third
to seventh ribs directly and the
eighth through tenth ribs
indirectly.
The xiphoid process, also
called the "tip", is located on
the bottom of the sternum. It is often
cartilaginous (cartilage), but does become
bony in later years.
These three segments of bone are usually
fused in adults.
The sternum serves an important function
in the body. The ribs are connected to it
by the costal cartilage. Without the
sternum, there would be a hole in the
bone structure in the middle of your chest,
right above your heart and lungs. The
sternum protects this vital area and
completes the circle of the rib cage.
The Ribs
The ribs are thin, flat, curved bones that
form a protective cage around the organs
in the upper body. They are comprised 24
bones arranged in 12 pairs.
These bones are divided into three
categories:
The first seven bones are called the true
ribs. These bones are connected to the
spine (the backbone) in back. In the front,
the true ribs are connected directly to the
breastbone or sternum by a strips of
cartilage called the costal
cartilage.
The next three pairs of bones
are called false ribs. These
bones are slightly shorter than
the true ribs and are connected
to the spine in back. However,
instead of being attached
directly to the sternum in front,
the false ribs are attached to the
lowest true rib.
The last two sets of rib bones
are called floating ribs.
Floating ribs are smaller than
both the true ribs and the false
ribs. They are attached to the
spine at the back, but are not
connected to anything in the
front.
The ribs form a kind of cage
the encloses the upper body.
They give the chest its familiar
shape.
The ribs serve several
important purposes. They
protect the heart and lungs
from injuries and shocks that
might damage them. Ribs also
protect parts of the stomach,
spleen, and kidneys. The ribs
help you to breathe. As you
inhale, the muscles in between
the ribs lift the rib cage up,
allowing the lungs to expand.
When you exhale, the rib cage
moves down again, squeezing
the air out of your lungs.
The vertebral column
The vertebral column (also called the
backbone, spine, or spinal column)
consists of a series of 33 irregularly
shaped bones, called vertebrae. These 33
bones are divided into five categories
depending on where they are located in
the backbone.
The first seven vertebrae are called the
cervical vertebrae. Located at the top of
the spinal column, these bones form a
flexible framework for the neck and
support the head. The first cervical
vertebrae is called the atlas and the
second is called the axis. The atlas' shape
allows the head to nod "yes" and the axis'
shape allows the head to shake "no".
The next twelve vertebrae are called the
thoracic vertebrae. These bones move
with the ribs to form the rear anchor of
the rib cage. Thoracic vertebrae are larger
than cervical vertebrae and increase in
size from top to bottom.
After the thoracic vertebrae, come the
lumbar vertebrae. These five bones are
the largest vertebrae in the spinal column.
These vertebrae support most of the
body's weight and are attached to many of
the back muscles.
The sacrum is a triangular bone
located just below the lumbar
vertebrae. It consists of four or
five sacral vertebrae in a child,
which become fused into a
single bone after age 26. The
sacrum forms the back wall of
the pelvic girdle and moves
with it.
The bottom of the spinal
column is called the coccyx or
tailbone. It consists of 3-5
bones that are fused
The appendicular skeleton is
composed of bones that anchor
the appendages to the axial
skeleton.
• The Upper Extremities
• The Lower Extremities
• The Shoulder Girdle
• The Pelvic Girdle--(the
sacrum and coccyx are
considered part of the
vertebral column)
The Upper Extremities
consists of three parts: the arm,
the forearm, and the hand.
The Arm
The arm, or brachium, is technically only
the region between the shoulder and
elbow. It consists of a single long bone
called the humerus. The humerus is the
longest bone in the upper extremity. The
top, or head, is large, smooth, and
rounded and fits into the scapula in the
shoulder. On the bottom of the humerus,
are two depressions where the humerus
connects to the ulna and radius of the
forearm. The radius is connected on the
side away from the body (lateral side)
and the ulna is connected on the side
towards the body (medial side) when
standing in the anatomical position.
Together, the humerus and the ulna make
up the elbow. The bottom of the humerus
protects the ulnar nerve and is commonly
known as the "funny bone" because
striking the elbow on a hard surface
stimulates the ulnar nerve and produces a
tingling sensation.
The Forearm
The forearm is the region between the
elbow and the wrist. It is formed by the
radius on the lateral side and the ulna on
the medial side when the forearm is
viewed in the anatomical position. The
ulna is longer than the radius and
connected more firmly to the humerus.
The radius, however, contributes more to
the movement of the wrist and hand than
the ulna. When the hand is turned over so
that the palm is facing downwards, the
radius crosses over the ulna. The top of
each bone connects to the humerus of the
arm and the bottom of each connects to
the bones of the hand.
 metacarpals) is called the proximal row,
the second row is the middle row, and the
farthest row is called the distal row. Each
The Hand finger has a proximal phalanx, a middle
The hand consists of three parts phalanx, and a distal phalanx, except the
(the wrist, palm, and five thumb (also called the pollex) which does
fingers) and 27 bones. not have a middle phalanx. The digits are
also numbered I to V starting from the
The wrist, or carpus, consists thumb.
of 8 small bones called the
carpal bones that are tightly
The lower extremity is composed of
bound by ligaments. These
the bones of the thigh, leg, foot, and the
bone are arranged in two rows
patella (commonly known as the
of four bones each. The top
kneecap).
row (the row closest to the
forearm) from the lateral
(thumb) side to the medial side
contains the scaphoid, lunate,
triquetral, and pisiform
bones. The second row from
lateral to medial contains the
trapezium, trapezoid,
capitate, and hamate. The
scaphoid and lunate connect to
the bottom of the radius.

The palm or metacarpus

consists of five metacarpal
bones, one aligned with each of
the fingers. The metacarpal
bones are not named but are
numbered I to V starting with
the thumb. The bases of the
The Thigh
metacarpal bones are connected
The thigh is the region between the hip
to the wrist bones and the
and the knee and is composed of a single
heads are connected to the
bone called the femur or thighbone. The
bones of the fingers. The heads
femur is the longest, largest, and strongest
of the metacarpals form the
bone in the body.
knuckles of a clenched fist.
The Leg
The fingers are made up of 14
The leg is technically only the region
bones called phalanges. A
from the knee to the ankle. It is formed by
single finger bone is called a
the fibula on side away from the body
phalanx. The phalanges are
(lateral side) and the tibia, also called the
arranged in three rows. The
shin bone, on the side nearest the body
first row (the closest to the
(medial side). The tibia connects to the
femur to form the knee joint
and with the talus, a foot bone,
to allow the ankle to flex and
extend. The tibia is larger than
the fibula because it bears most
of the weight, while the fibula
serves as an area for muscle
attachment.
The Foot
The foot, or pes, contains the
26 bones of the ankle, instep,
and the five toes. The ankle, or
tarsus, is composed of the 7
tarsal bones which correspond
to the carpals in the wrist. The
largest tarsal bone is called the
calcaneus or heel bone. The
talus rests on top of the
calcaneus and is connected to
the tibia. Directly in front of
the talus is the navicular bone.
The remaining bones from
medial to lateral are the
medial, intermediate, the
lateral cuneiform bones, and
the cuboid bone.
The metatarsal and phalanges
bones of the foot are similar in
number and position to the
metacarpal and phalanges
bones of the hand. The five
metatarsal bones are numbered
I to V starting on the medial
side with the big toe. The first
metatarsal bone is larger than
the others because it plays a
major role in supporting the
body's weight. The 14
phalanges of the foot, as with
the hand, are arranged in a
proximal row, a middle row,
and a distal row, with the big
toe, or hallux, having only a
proximal and distal phalanx.
The foot's two arches are formed by the
structure and arrangement of the bones
and are maintained by tendons and
ligaments. The arches give when weight
is placed on the foot and spring back
when the weight is lifted off of the foot.
The arches may fall due to a weakening
of the ligaments and tendons in the foot.
The Patella
The patella or kneecap is a large,
triangular sesamoid bone between the
femur and the tibia. It is formed in
response to the strain in the tendon that
forms the knee. The patella protects the
knee joint and strengthens the tendon that
forms the knee.
The bones of the lower extremities are the
heaviest, largest, and strongest bones in
the body because they must bear the
entire weight of the body when a person
is standing in the upright position.
The Shoulder Girdle, also called the
Pectoral Girdle, is composed of four
bones: two clavicles and two scapulae .
The clavicle, commonly called the
collarbone, is a slender S-shaped bone
that connects the upper arm to the trunk
of the body and holds the shoulder joint
away from the body to allow for greater
freedom of movement. One end
of the clavicle is connected to
the sternum and one end is
connected to the scapula.
The scapula is a large,
triangular, flat bone on the back
side of the rib cage commonly
called the shoulder blade. It
overlays the second through
seventh rib and serves as an
attachment for several muscles.
It has a shallow depression
called the glenoid cavity that
the head of the humerus (upper
arm bone) fits into.
Usually, a "girdle" refers to
something that encircles or is a
complete ring. However, the
shoulder girdle is an
incomplete ring. In the front,
the clavicles are separated by
the sternum. In the back, there
is a gap between the two
scapulae.
The primary function of the
pectoral girdle is to provide an
attachment point for the
numerous muscles that allow
the shoulder and elbow joints
to move. It also provides the
connection between the upper
extremities (the arms) and the
axial skeleton.
The Pelvic Girdle
The Pelvic Girdle, also called the hip
girdle, is composed to two coxal (hip)
bones. The coxal bones are also called the
ossa coxae or innominate bones. During
childhood, each coxal bone consists of
three separate parts: the ilium (denoted in
purple above), the ischium (denoted in
red above), and the pubis (denoted in
blue above). In an adult, these three bones
are firmly fused into a single bone. In the
picture above, the coxal bone on the left
side has been divided into its component
pieces while the right side has been
preserved.
In the back, these two bones meet on
either side of the sacrum. In the front,
they are connected by a muscle called the
pubic symphysis (denoted in green
above).
The pelvic girdle serves several important
functions in the body. It supports the
weight of the body from the vertebral
column. It also protects and supports the
lower organs, including the urinary
bladder, the reproductive organs, and the
developing fetus in a pregnant woman.
The pelvic girdle differs between men and
woman. In a man, the pelvis is more
massive and the iliac crests are closer
together. In a woman, the pelvis is more
delicate and the iliac crests are farther
apart. These differences reflect the
woman's role in pregnancy and delivery
of children. When a child is born, it must
pass through its mother's pelvis. If the
opening is too small, a cesarean section
may be necessary.
Other Bone Diseases
Bone spurs, also known as
osteophytes, are bony
projections that form along
joints. Bone spurs form due to
the increase in a damaged
joint's surface area. This is
most commonly from the onset
of arthritis. Bone spurs usually
limit joint movement and
typically cause pain.
Bone spurs form naturally on
the back of spine as a person
ages and are a sign of
degeneration in the spine. In
this case the spurs are not the
source of back pains, but
instead are the common
symptom of a deeper problem.
However, bone spurs on the
spine can impinge on nerves,
which leave the spine for other
parts of the body.
This impingement can cause
pain in both upper and lower
limbs and a numbness or
tingling sensations in the hands
and feet due to the nerves
supplying sensation to their
dermatomes.
Cause
Osteophyte formation has been
classically related to any
sequential and consequential
changes in bone formation due
to aging, degeneration,
mechanical instability, and
disease. Often osteophytes
form in osteoarthritic joints due
to damage and wear from
inflammation. Calcification and
new bone formation can also
occur in response to
mechanical damage in joints, or
at the attachment points for ligaments and
tendons.
Symptoms:
• Back ache
• Mild pain in the neck
• Pain in the shoulders in case the
bone spur occurs in the cervical
spine
• Headache
• Pain in thighs when bone spur takes
place in the lumbar spine
• Numbness
• General weakness
• Pain in arms and legs
Diagnostic
Electroconductive tests are
commonly performed to document the
degree and severity of spinal nerve injury.
The EMG and nerve conduction test
(EMG/NCV) tests will exclude peripheral
nerve compression such as carpal tunnel
syndrome.
Radiographs begin with an x-ray of the
spine to determine the extent of arthritic
changes and bone spur formation. With
these films the physician may determine
if destructive changes are present or
further radiographic images are indicated.
Computerized tomography (CT scans)
with myelography and/or MRI scans can
provide details about change in the spinal
architecture and the degree of nervous
system compression. With these films the
clinician will correlate clinical symptoms
with radiographic findings and
recommend the corrective course of
action, often seeking the consultation of
the spine surgeon.

Radiograph of bone spur
Treatments
There's no specific treatment
for bone spurs.
If your bone spurs don't cause
you any pain or if they don't
limit any range of motion in
your joints, then you likely
won't need treatment. If you
need treatment, it's typically
directed at the underlying
problem to prevent further joint
damage.
Medications
If your bone spurs are causing
pain, your doctor may
recommend nonsteroidal anti-
inflammatory drugs (NSAIDs)
to ease the pain.
Surgery
Bone spurs that limit your
range of motion or cause other
problems that limit your ability
to go about your day may
require surgery. What surgical
options you have will depend
on where your bone spurs are located and
your particular situation.
Fibrous dysplasia is a disease that
causes bone thinning and growths or
lesions in one or more bones of the
human body.
Causes
Fibrous dysplasia is very rare; not much
is known about it, and there is no known
cure. However, it is known that it is
caused by a genetic mutation that occurs
sometime during fetal development, and
is not hereditary. There are two types of
fibrous dysplasia: 1. Monostotic
(Involving a single bone), and 2.
Polystotic (Involving many bones). The
most severe form of
polystotic fibrous dysplasia is known as
Albright Syndrome.
Symptoms
Fibrous dysplasia can affect any bone in
your body. Most people with the disorder
have only one affected bone — a form
called monostotic fibrous dysplasia —
and develop no signs or symptoms. When
the condition affects more than one bone,
it's known as polyostotic fibrous
dysplasia. Bones most commonly affected
are:
• Thighbone (femur)
• Shinbone (tibia)
• Pelvic bones
• Ribs
• Skull
• Facial bones
• Upper arm bone (humerus)
Fibrous dysplasia may cause few or no
signs and symptoms, particularly if the
condition is mild. Signs and symptoms
may develop during childhood,
adolescence or adulthood. If
you have the polyostotic form,
you're more likely to develop
signs and symptoms, usually by
age 10. More severe fibrous
dysplasia may cause:
• Bone pain
• Difficulty walking
• Bone deformities
• Fractures
Diagnosis
If you have monostotic fibrous
dysplasia, you may not know it
until it's discovered
incidentally on an X-ray for
another condition. If you have
signs and symptoms, your
doctor will perform a physical
examination and order X-rays
of the affected bones. On X-
ray, fibrous dysplasia appears
as an abnormal section of bone
(lesion) that has the hazy
appearance of ground glass.
take up the tracers and emit
radiation that's captured by a
special camera, which
• produces a picture of your skeleton.
Your doctor may order a bone scan
to determine whether your fibrous
dysplasia is monostotic or
polyostotic.
• Bone biopsy. Surgically removing a
sample of affected bone for
examination under a microscope is
necessary only if your doctor
suspects cancer. During a biopsy, a
surgeon removes a small piece of
your affected bone for analysis in a
laboratory.

In some cases, your doctor may

order more tests to confirm
diagnosis or to determine the
extent of the disorder. They
include:

• Imaging tests.
Computerized
tomography (CT) or
magnetic resonance
imaging (MRI) scans
may be used to
determine how
extensively your bones
are affected. Fibrous Dysplasia-MRI.
• Bone scan. This test uses
radioactive tracers,
which are injected into
your body. Your bones
Treatment generally well tolerated, but may irritate
If you have mild fibrous your gastrointestinal tract. Some
dysplasia that's discovered bisphosphonates aren't available as oral
incidentally and you have no medications, and you must receive them
signs or symptoms, your risk of through a vein (intravenously). The drug
developing deformity or tends to work faster when you receive it
fracturing your bone is low. through a vein than if you take it orally,
Your doctor can monitor your and intravenous administration provides
condition with follow-up X- an option when you can't tolerate or
rays every six months. If there's otherwise aren't a candidate for oral
no progression, you don't need bisphosphonates. You can't take
treatment. bisphosphonates if you have serious
If you develop signs and kidney disease or low blood calcium
symptoms, treatment may levels.
include medications or surgery.
Surgery
Medications
Your doctor may recommend
Medications called surgery in order to:
bisphosphonates, including
pamidronate (Aredia) and • Correct a deformity
alendronate (Fosamax), are • Fix a fracture
used to inhibit bone • Remove an affected area of bone
breakdown, preserve bone (lesion) that's causing you difficulty
mass and even increase bone
• Relieve pressure on a nerve,
density in your spine and hip,
particularly if the lesion is in your
reducing the risk of fractures.
skull or face
Doctors use these medications
primarily for adults to treat
Surgery may involve removing the bone
osteoporosis and increase bone
lesion and replacing it with bone from
density, but bisphosphonates
another part of your body. Your surgeon
may also reduce bone pain
may insert metal plates, rods or screws to
associated with fibrous
stabilize the bone and the graft. Risks
dysplasia, and, in some cases,
include infection, blood clots and
improve bone formation.
bleeding. In addition, a bone graft may
not last.
Little is known about the use of
bisphosphonates for children
and adolescents, but some
studies indicate they may help
relieve pain in children and
adolescents with severe fibrous
dysplasia.
Oral bisphosphonates are
Osteopenia is a condition
where bone mineral density is
lower than normal. It is
considered by many
doctors to be a precursor to
osteoporosis. However, not
every person diagnosed with
osteopenia will develop
osteoporosis. More specifically,
osteopenia is defined as a bone
mineral density T score
between -1.0 and -2.5.
Causes
Like osteoporosis, osteopenia
occurs more frequently in post-
menopausal women as a result
of the loss of estrogen. It can
also be exacerbated by lifestyle
factors such as lack of exercise,
excess consumption of alcohol,
smoking or prolonged use of
glucocorticoid medications
such as those prescribed for
asthma.
The condition can occur in
young women who are athletes.
It is associated with female
athlete triad syndrome as one
of the three components, the
other two being amenorrhea
and disordered eating. Female
athletes tend to have lower
body weight, lower fat
percentage, and higher
incidence of asthma than their
less active peers. The low
estrogen levels (stored in body
fat) and / or use of
corticosteroids to treat asthma
can significantly weaken bone
over long periods of time.
Distance runners in particular
are also discouraged from
consuming milk products when
training, which would result in lower
calcium absorption than other groups.
Symptoms
There are no symptoms associated with
the early stages of osteopenia. As such,
osteopenia is a silent risk factor for
fractures. Symptoms occurring during
later stages include fractures of the
vertebrae, wrists or hips (usually the first
indication); low back pain; neck pain;
bone pain and tenderness; loss of height
over time; and a stooped posture.
Diagnosis
The pharmaceutical company Merck,
which sells the anti-bone-loss drug
Fosamax, estimated in 2003, from its own
market research, that about 8 million
women had been found to have
osteopenia and about a third of them were
taking an osteoporosis drug. Scans of
bones anywhere in the body can be done
with X-rays, known as Dexa (Dual energy
X-ray absorptiometry). Scans can also be
done with portable scanners using
ultrasound, and portable X-ray machines
can measure density in the heel. A study
paid for by Merck found that the extent to
which osteopenia was diagnosed varied
from 28 to 45 percent, depending on the
type of machine.
radiograph of knees shows periarticular osteopenia,
prominent tibial spines, and interosseous cysts (arrows)
Paget's disease, otherwise
known as osteitis deformans, is
a chronic disorder that typically
results in enlarged and
deformed bones. It is named
after Sir James Paget, the
British surgeon who first
described this disease. The
excessive breakdown and
formation of bone tissue that
occurs with Paget's disease can
cause bone to weaken, resulting
in bone pain, arthritis,
deformities, and fractures.
Cause
Although the exact cause of
Paget's disease is unknown, it
appears to run in families. Up
to 30 % of people with the
disease have other family
members who also have it.
Some researches believe that a
virus may be involved, but a
specific virus has not been
identified.
Whatever the cause, Paget's
disease results in abnormal
bone remodeling (the normal
process of bone breakdown and
rebuilding). In Paget's disease,
when bone is broken down, it is
replaced with soft bone. The
bone is weak and can bend
easily. As bones rebuild, they
can also become larger than
before.
Symptoms
Many patients do not know
they have Paget's disease
because they have a mild case
with no symptoms.
Sometimes, symptoms may be
confused with those of arthritis
or other disorders. In other
cases, the diagnosis is made only after
complications have developed. Symptoms
can include:
• Bone pain is the most common
symptom. Bone pain can occur in
any bone affected by Paget's
disease. It often localizes to areas
adjacent to the joints.
• Headaches and hearing loss may
occur when Paget's disease affects
the skull.
• Pressure on nerves may occur when
Paget's disease affects the skull or
spine.
• Somnolence (drowsiness) due to
vascular steal syndrome of the
skull.
• Paralysis due to vascular steal
syndrome of the vertebrae.
• Increased head size, bowing of
limb, or curvature of spine may
occur in advanced cases.
• Hip pain may occur when Paget's
disease affects the pelvis or
thighbone.
• Damage to joint cartilage may lead
to arthritis.
• Teeth may spread intraorally.
• Chalkstick fractures.
Diagnosis
Paget's disease may be diagnosed using
one or more of the following tests:
• Pagetic bone has a characteristic
appearance on x-rays. A skeletal
survey is therefore indicated.
• An elevated level of alkaline
phosphatase in the blood in
combination with normal calcium,
phosphate, and aminotransferase
levels in an elderly patient are
suggestive of Paget's disease.
 • Bone scans are useful in
determining the extent
and activity of the
condition. If a bone scan
suggests Paget's disease, the
affected bone(s) should be x-
rayed to confirm the diagnosis.
Radiograph of Tibia w/ Paget’s Disease.
Types of physicians
The following types of medical
specialists are generally
knowledgeable about treating
Paget's disease.
• Endocrinologists --
Internists who specialize
in hormonal and
metabolic disorders.
• Rheumatologists --
Internists who specialize
in joint and muscle
disorders.
• Specialists -- Orthopedic
surgeons, neurologists,
and otolaryngologists
(physicians who
specialize in ear, nose,
and throat disorders) may be called
upon to evaluate specialized
symptoms.
Drug therapy
The goal of treatment is to relieve bone
pain and prevent the progression of the
disease. The U.S. Food and Drug
Administration has approved the
following treatments for Paget's disease:
Bisphosphonates
Five bisphosphonates are currently
available. In general, the most commonly
prescribed are the three most potent
bisphosphonates: Actonel, Fosamax and
Aredia. Didronel and Skelid may be
appropriate therapies for selected patients
but are less commonly used. As a rule,
bisphosphonate tablets should be taken
with 6–8 oz of tap water (not from a
source with high mineral content) on an
empty stomach. None of these drugs
should be used by people with severe
kidney disease.
Didronel (etidronate disodium) -- Tablet;
approved regimen is 200–400 mg once
daily for 6 months; the higher dose (400
mg) is more commonly used; no food,
beverages, or medications for 2 hours
before and after taking; course should not
exceed 6 months, but repeat courses can
be given after rest periods, preferably of
3–6 months duration.
Aredia (pamidronate disodium) --
Intravenous; approved regimen 30 mg
infusion over 4 hours on 3 consecutive
days; more commonly used regimen 60
mg over 2–4 hours for 2 or more
consecutive or non-consecutive days.
Fosamax (alendronate sodium) -- Tablet;
40 mg once daily for 6 months; patients
should wait at least 30 minutes after
taking before eating any food,
drinking anything other than
tap water, taking any
medication, or lying down
(patient
may sit).
Skelid (tiludronate disodium)
-- Tablet; 400 mg (two 200 mg
tablets) once daily for 3
months; may be taken any time
of day, as long as there is a
period of 2 hours before and
after resuming food,
beverages, and medications.
Actonel (risedronate sodium) --
Tablet; 30 mg once daily for 2
months; patients should wait at
least 30 minutes after taking
before
eating any food, drinking
anything
other than tap water, taking any
medication, or lying down
(patient
may sit).
Calcitonin
Miacalcin is administered by
injection; 50 to 100 units daily
or 3 times per week for 6-18
months. Repeat courses can be
given after brief rest periods.
Miacalcin may be appropriate
for certain patients but is
seldom used. The nasal spray
form of this drug is not
approved for the treatment of
Paget's disease.
Surgery
Medical therapy prior to surgery helps to
decrease bleeding and other
complications. Patients who are having
surgery should discuss pre-treatment with
their physician. There are generally three
major complications of Paget's disease for
which surgery may be recommended.
• Fractures -- Surgery may allow
fractures to heal in better position.
• Severe degenerative arthritis -- If
disability is severe and medication
and physical therapy are no longer
helpful, joint replacement of the
hips and knees may be considered.
• Bone deformity -- Cutting and
realignment of Pagetic bone
(osteotomy) may help painful
weight bearing joints, especially the
knees.
Complications resulting from enlargement
of the skull or spine may injure the
nervous system. However, most
neurologic symptoms, even those that are
moderately severe, can be treated with
medication and do not require
neurosurgery.
Diet and Exercise
In general, patients with Paget's disease
should receive 1000-1500 mg of calcium,
adequate sunshine, and at least 400 units
of vitamin D daily. This is especially
important in patients being treated with
bisphosphonates. Patients with a history
of kidney stones should discuss calcium
and vitamin D intake with their physician.
Exercise is very important in maintaining
skeletal health, avoiding weight gain, and
maintaining joint mobility. Since undue
stress on affected bones should be
avoided, patients should discuss any
exercise program with their
physician before beginning.

Renal osteodystrophy is a
bone pathology, characterized
by defective mineralization,
that results from kidney
disease. Renal osteodystrophy
comes in two different forms,
high bone turnover and low
bone turnover.

Symptoms
Renal osteodystrophy may
exhibit no symptoms; if it does
show symptoms, they include: Radiograph of Fingers w/ osteodystrophy

• Bone pain Treatment

• Joint pain Treatment for renal osteodystrophy
• Bone deformation includes:
• Bone fracture
• calcium and vitamin D
Diagnosis supplementation
Renal osteodystrophy is • restrictionof dietary phosphate
usually diagnosed after • phosphate binders such as calcium
treatment for end-stage renal carbonate, calcium acetate,
disease begins. Blood tests sevelamer hydrochloride, or
will indicate decreased lanthanum carbonate
calcium and calcitriol and • cinacalcet
increased phosphate and • renal transplantation
parathyroid hormone. X-rays
• hemodialysis five times a week is
will also show bone features of
thought to be of benefit.
renal osteodystropy
(chondrocalcinosis at the
knees and pubic symphysis,
osteopenia and bone
fractures) but may be difficult
to differentiate from other
conditions.
Giant cell tumor of the
bone (also called giant cell
myeloma or osteoclastoma) is a
relatively uncommon tumor. It
is characterized by the presence
of multinucleated giant cells
(osteoclast-like cells). These
tumors are generally benign. In
most patients, the tumors are
slow to develop, but may recur
locally in as many as 50% of
cases. Metastasis to the lungs
may occur.
Cause
While the exact cause of giant
cell tumors remains unknown,
in some cases, they have been
linked to Paget's disease.
Paget's disease of the bone is a
chronic bone disorder in which
bones become enlarged and
deformed.
Symptoms
The following are the most
common symptoms of a giant
cell tumor. However, each
individual may experience
symptoms differently.
Symptoms may include:
• pain at the adjacent
joint
• a visible mass
• swelling
• bone fracture
• limited movement in
the adjacent joint
• fluid accumulation in
the joint adjacent to the
affected bone
The symptoms of a giant cell
tumor may resemble other
medical conditions or
problems. Always consult your physician
for a diagnosis.
Diagnosed
In addition to a complete medical history
and physical examination, diagnostic
procedures for giant cell tumors may
include the following:
• x-rays - a diagnostic test which
uses invisible electromagnetic
energy beams to produce images
of internal tissues, bones, and
organs onto film.
• radionuclide bone scans - a
nuclear imaging method to
evaluate any degenerative and/or
arthritic changes in the joints; to
detect bone diseases and tumors;
to determine the cause of bone
pain or inflammation. This test is
to rule out any infection or
fractures.
• biopsy - a procedure in which
tissue samples are removed (with
a needle or during surgery) from
the body for examination under a
microscope; to determine if cancer
or other abnormal cells are
present.
X-ray of a giant cell bone tumor in the head of the 4th
metacarpal of the left hand.
Osteitis fibrosa cystica,
also known as Von
Recklinghausen's disease of
bone, is characterized by
increased osteoclastic
resorption of calcified bone
with replacement by fibrous
tissue. It may be caused by
Secondary
hyperparathyroidism or other
causes of the rapid
mobilization of mineral salts.
The bone problems associated
with the disorder osteitis
fibrosa are usually reversible
with surgery, except in the case
of fluid filled cysts, which
require non-surgical attention.
Causes
Anything that causes
hyperparathyroidism can lead
to Osteitis fibrosa cystica. It is
particuarly prevalent
among patients with end stage
renal disease due to the
decreased synthesis of
Vitamin D from the kidneys.
phosphorus. X-rays may indicate thin
bones, fractures, bowing, and cysts. The
cysts may be lined by osteoclasts, filled
with fibrous stroma and sometimes blood
("brown tumors"). The skull may look
like "ground glass" or "salt and pepper."
The outer part of bones may be eroded;
the most sensitive area to check is the
fingers. Teeth X-rays may also be
abnormal.
Diagnosis
Blood tests show a high level of calcium,
parathyroid hormone, and alkaline
phosphatase (a bone chemical).
Phosphorus may be low.X-rays may show
thin bones, fractures, bowing, and cysts.
Teeth x-rays may also be abnormal.A
bone x-ray may be done. People with
hyperparathyroidism are more likely to
have osteopenia (thin bones) or
osteoporosis (very thin bones) than to
have full-blown osteitis fibrosa.

Symptoms
Osteitis fibrosa cystica can lead
to bone pain or tenderness,
pathological fractures in the
arms, legs, or spine, and
deformities (bowing of the
bones). Being a precursor to
the disorder,
hyperparathyroidism itself may
cause kidney stones, nausea,
constipation, fatigue and
weakness. Blood tests show a This is a cross section from a femur of a
high level of serum calcium patient who suffered from
and alkaline phosphatase, and hyperparathyroidism.
low serum
Treatment juveniles. In the adult group of cases
The main treatment for trauma is thought to be the main or
hyperparathyroidism is surgery perhaps the sole factor in determining the
to remove the abnormal onset of osteochondritis dissecans. The
parathyroid gland(s). Newer trauma may be endogenous and/or
techniques use radioactive exogenous. Interestingly, the incidence of
tracers and rapid parathyroid overuse injuries in young athletes is on
hormone blood tests to make the rise and accounts for a significant
the surgery quicker and easier. number of visits to the primary care
If surgery is not possible, drugs office; this reinforces the theory that OCD
can sometimes be used to lower may be associated with increased
calcium levels. participation in sports and subsequent
trauma.
Osteochondritis
Symptoms
dissecans
The symptoms of osteochondritis
(typically abbreviated to OCD)
dissecans are pain and swelling of the
is a form of osteochondritis. It
affected joint, catching and locking on
is commonly accepted that
movement and a restriction in the range
trauma, avascular necrosis and
of movement. These symptoms
other causative factors
characterize many knee conditions and
affecting the subchondral
may have a broad range of other causes,
(below cartilage) bone can lead
making OCD relatively hard to clinically
to the loss of support for
diagnose.
adjacent cartilaginous
structures and precede the
Diagnosis
separation of an articular
To determine whether pains are
fragment from the underlying
osteochondritis dissecans, an MRI, CT
bone and formation loose
scan or X-ray can be performed to show
bodies.
necrosis of subchondral bone and/or
formation of loose fragments. In specific
Cause
cases, if caught early enough, a harmless
Although the etiology is not
dye will be injected into the blood stream
certain, possible causative
to show where calcium will accumulate.
factors include repetitive
trauma, ischemia, hereditary
Physical examination
and endocrine factors,
avascular necrosis, rapid
A special test known as the "Wilson sign"
growth, deficiencies and
has been described to locate OCD lesions
imbalances in the ratio of
of the femoral condyle. The test is
calcium to phosphorus, and
performed by slowly extending the knee
anomalies of ossification.
from 90 degrees while maintaining
Trauma, rather than avascular
internal rotation. Pain reported at 30
necrosis, is thought to be the
degrees of flexion and relief with tibial
factor which localizes and
external rotation is a positive result.
determines the development of
osteochondritis dissecans in
 Non-surgical treatment

Candidates for non-operative treatment

include those who are skeletally immature
with an intact lesion and no loose bodies.
Non-operative management may include
activity modification, protected weight
bearing (partial or non-weight bearing),
MRI of the elbow showing edema in the and immobilization. The goal of non-
capitellum with an osteochondritis
dissecans lesion. operative intervention is to promote
healing in the subchondral bone and
Treatment potentially prevent chondral
Treatment options include collapse, subsequent fracture, and crater
modified activity with or formation.
without weight-bearing;
immobilization; cryotherapy; Surgical treatment
anti-inflammatories; drilling of
subchondral bone to improve The choice of surgical verse non-surgical
vascularity; microfracture; treatments for osteochondritis dissecans is
reattachment and removal of still controversial. Consequently, the type
loose bodies and autologous and extent of surgery necessary varies
osteochondral plugs (OATS). based on patient age, severity of the
The principles of treatment are lesion, and personal bias of the treating
to enhance the healing potential surgeon—entailing an exhaustive list of
of subchondral bone, fix suggested treatments. Thus, a variety of
unstable fragments while surgical options exist for the treatment of
maintaining joint congruity, persistently symptomatic, intact, partially
and to replace the damaged detached, and completely detached OCD
bone and cartilage with implant lesions.
tissues or cells that can replace
bone and grow cartilage.
However, the capacity of
articular cartilage for repair is
limited. Partial-thickness
defects in the articular cartilage
do not heal spontaneously.
"Injuries of the articular
cartilage that do not penetrate
the subchondral bone" do not
heal and usually progress to the
"degeneration of the articular
surface." As a result, surgery is
often required in even
moderate cases (stage II, III) of
OCD.