Ch 8 Orthopedics/ Orthopaedics Them Bones –

1. Ch 8 Orthopedics/ Orthopaedics Them Bones – The Skeletal SystemBranch of medicine pertaining to study and tx of skeletal/myo abnormalities and dz nmhm.washingtondc.museum/exhibits

2. Who does what? Orthopedic physician- also called Orthopod. -ics means knowledge; practice orth/o means straight; -ped/o means child We who study bones are called Osteologists! (just for today) What about an Orthotist? Braces, supports http://www.stereofoto.de/gallery/index.html

3. Medications (Rx) we might expect to see used in this system • Calcium mineral contained in many OTC antacids Tums, CitraCal, Oystercal, etc. Used to prevent osteoporosis and treat hypocalcemia And let’s talk about drinking sodas… • Gold Compounds yes, actual gold Treats rheumatoid arthritis by inhibiting dz progression. No reversal yet. • Analgesics (Tylenol/acetominophen) Suppress inflammation, decrease pain • NSAIDs (nonsteroidal anti-inflammatory drugs) These are not ‘Steroids’ ibuprofin/Motrin/Advil, naproxin/Aleve, ketoprofin/Orudis, Relafen • COXX 2 inhibitors (Celebrex, Vioxx), Toradol, Relieve mild to moderate pain and reduce inflammation

4. Corticosteroid drugs (prednisone, hydrocortisone, Depo-Medrol inj.) - suppress inflammation. p.o. or injected into intra-articular space Chemotherapy drugs (Adriamycin, VePesid) Kill ca cells in bones as they rapidly divide Pushing more pills

5. Still more meds • Salicylates (aspirin, ASA, Aspergum, Doan’s Regular Strength Tablets) Relieve mild to moderate pain; reduce inflammation Oldest arthritis drug – Aspirin is reformulated willow bark • Narcotic and opioid analgesics (Demerol, Darvon, morphine, codeine, Fiorenal, Percodan, Vicodin, oxycodone hydrochloride) Relieve moderate to severe pain. Derived from opium or synthetic. Strong addictive properties – used in short term prescription. May be used post-operatively, especially for orthopedic procedures • Skeletal muscle relaxants (Soma, Parafon Forte, Relaxazone) Relieve myo (muscle) spasms and stiffness. Also used to treat spasticity from palsy, ms, stroke, spinal cord injury

6. Bone resorption-inhibitor drugs Bisphosphates and Diphosphonates – inhibit osteoclasts. (Fosamax, Boniva, Miacalcin) • Associated with mandibular osteonecrosis; twice as affected as maxilla. • May be associated with dental surgical procedures – talk to your doctors and make them talk to each other! • Severe bone, joint, musculoskeletal pain is reported months after d/c of Rx, causing misdiagnosis of etiology. • Some of these rx help bone to thicken, but in some new bone tissue is brittle; begins to thin in a few years.

7. Changes in bone remodeling following menopause result in bone loss • Atypical Fractures May Complicate Long-Term Bisphosphonate Therapy • Laurie Barclay, MD — Another increased risk is contralateral atypical fractures. • bisphosphonate therapy may suppress bone remodeling to the extent that normal bone repair is impaired, resulting in increased fracture risk. • These "atypical" fractures associated with suppression of bone turnover often affect sites seldom affected by osteoporotic fractures, such as subtrochanteric femur. Features characteristic of atypical subtrochanteric femur fracture include no history of trauma before fracture, prodromal thigh pain, and radiological findings.

8. What do our bones do? • Skeletal system • AKA skeletomuscular system • AKA musculoskeletal system • Structural support, aids muscles and nerves to initiate movement (leverage, right?), maintain position, protect vital organs (with a few holes) • National Museum of Health and Medicine “The Human Body Revealed” http://www.nmhm.washingtondc.museum

9. Marrow • Hematopoiesis = formation of blood cells takes place in red marrow of long and flat bones. • In infants, red marrow is found in bone cavities. Mostly replaced by yellow marrow for fat storage with age. • In adults, red marrow is limited to spongy (Cancellous) bone in skull, ribs, sternum, clavicles, vertebrae and that donor site, the pelvis.

10. Appendicular Skeleton Bones of Appendages: Shoulder Girdle, Pelvic Girdle, Legs Axial Skeleton Cranial and Facial Auditory ossicles Hyoid Vertebral Column Thoracic Cage (sternum and ribs) 2 Skeletons?

11. L o n g bones • Humerus Your ‘Popeye’ muscle attaches here • Radius Your forearm • Ulna Your forearm, part ll • Femur Your thighbone • Tibia Your shinbone • Fibula The lateral lower leg - ends at your lateral ankle • Phalanges Your fingers or toes

12. SedsiaomBonesYour lovely little sesame-shaped patella

13. S H O R T Bones • Carpals Think ‘wrist’ Carpal tunnel syndrome • Tarsals Think ‘ankle’

14. F L A TBONES • Sternum - joins to ribcage on your anterior • Ribs (yes, I know they are curved) • Scapula (again, I don’t make the rules)

15. I r r e g u la r Bones • Vertebrae bones of the spine • Facial bones think of those zygomatic bones!

16. Let’s look at a bone Page 412 • Let’s find these landmarks: • Epiphyses - * Cancellous distal and or spongy bone proximal * Compact bone • Articular * Red bone marrow cartilage * Yellow bone marrow • Diaphysis * Epiphyseal lines • Periosteum What kind of bone is this? http://www.pediatricorthopedics.com/Topics/Bones/Hip/hip.html

17. Remember how we learned where the Coronal Plane was? See the Zygomatic bone of the cheek? Cranial bones and sutures

18. Your Cranium - Frontal, parietal,temporal, occipital -AKA occiput Sphenoid, frontal, ethmoid, and maxilla –home to sinuses Sutures or sulces: (started as fontanels) Coronal or Sagittal Foramen magnum Facial bones – Maxilla – upper jaw Mandilla – lower jaw – the movable one, thank goodness! Etthmoid bone with Olfactory nerve http://training.seer.cancer.gov/module_anatomy/unit3_8_quiz_dd_01.html http://www.getbodysmart.com/ap/skeletalsystem/skeleton/axial/skull/menu/animation.html Mo bones-cranium & facial bones

19. links • http://training.seer.cancer.gov/module_anatomy/unit3_8_quiz_dd_01.html • http://www.getbodysmart.com/ap/skeletalsystem/skeleton/axial/skull/menu/animation.html

20. Get some backbone • Vertebral column – protector of spinal cord 24 vertebrae, sacrum and coccyx • Cervical – your neck - first 7 vertebrae C1-C7 • Thoracic – next 12 – provide site for posterior rib attachments T1-T12 • Lumbar – next 5 - low back L1-L5 • Intervertebral disks –made of cartilage to pad between vertebrae • Sacrum – triangular or wedge shaped bone of lower spine • Coccyx – tailbone

21. Clavicle (collarbone) – anterior Scapula (shoulder blade) Joined together at most lateral and highest point of shoulder by Acromion Process (part of scapula) www.drloweshoulder.com/.../bone_shoulder.gif The shoulder

23. See where shoulder bursitis happens?

24. The arm and hand • Humerus - upper arm –what shape bone? • Radius - lateral bone of forearm • Ulna - medial bone of forearm • Carpals - wrist Tarsals - ankle • Metacarpals – (Meta?) bones of palm • Phalanges- finger/toe bones

25. The chest or thorax (thoracic cavity, remember?) • Sternum - breastbone Xyphoid process-projection at distal end. Manubrium -Curvy notch at proximal end. • Ribs Protectors of heart and lungs, among other things

26. Pelvis – 3 fused bones and 2 parts of vertebral column Ilium –largest of pelvic bones - you feel it as your ‘hip’ bone Red bone marrow donor site Bone marrow aspiration - aspiration needle used to draw out marrow Ischium – ‘sit’ bones - lowest and strongest of pelvic bones Pubis – wrapping around toward anterior of pelvis and connecting at cartilagenous joint called Symphysis pubis Don’t forget Sacrum and Coccyx The hip bone’s connected to….

27. Acetabulum - socket in pelvis where femur articulates Sacrum – 4th segment of vertebral column joins ilium at SI joint (Sacroiliac joint) Coccyx – tailbone, remember? ‘As we move caudally’, or ‘toward the coccyx’ THR Total Hip Replacement Surgical replacement of femoral head and acetabulum with synthetic components So if ‘-plasty’ means surgical repair of, and ‘arthr/o’ means joint, see how T/PHR (Total or Partial Hip Replacement) is a hip arthroplasty? Still with the pelvis….

28. Femur –heaviest, strongest, longest bone * rounded head fits into acetabulum to articulate with pelvis to form hip joint * neck is part that juts out from acetabulum to meet shaft of this long bone Patella – that sesamoid bone- protects knee joint Tibia - shin bone Fibula – lateral lower leg bone – non-weightbearing --you feel its distal end at lateral ankle Lateral malleoulus and medial malleolus Shake a leg library.thinkquest.org/5777/ske5.htm

29. Tarsals – ankle bones *Talus –joins Tibia and Fibula to make ankle joint; sits on top of *Calcaneus – largest foot bone, normally called heelMetatarsals – bones of footPhalanges - toe bones - share same name as fingers www.eorthopod.com

30. Roots in the skeletal system • Kypho hunchback, humpback • kyphosis – abnormal condition of a dorsally rounded or hunched thoracic spine • Lordo swayback, swayed back lordosis – abnormal condition of lumbar spine curving anteriorly Scolio crooked, bent side to side scoliosis – abnormal condition where spine is crooked or bent laterally, and perhaps also twisted or rotated

31. More roots carpo wrist bones chondro cartilage claviculo clavicle coccygo coccyx costo rib cranio skull femoro femur fibulo fibula humero humerus

32. And…….. ilio ilium ischio ischium lamino lamina thin flat plate lumbo lumbar maxillo maxilla or upper jaw - think ‘maxillary sinuses’ mandibulo mandible - lower jaw metacarpo hand bones metatarso foot bones

33. still more roots • myelo bone marrow • myo muscle • ortho straight • osteo bone • arthro joint • patello patella • phalangeo finger or toe bone • pubio/pubo pubis;anterior pelvis • radio radius • scapulo scapula • sterno sternum • tarso tarsals; ankle • vertebro vertebra; vertebrae

34. Skeletal System Prefixes and Suffixes Prefixes; sub- remember that one? and supra- above • Suffixes: -blast immature -clasis surgical fracture -malacia softening -oma tumor -osis abnormal condition

35. putting some things together • sub meaning under, below • ar,al meaning pertaining to SUBMANDIBULAR pertaining tobelow mandible SUBSTERNAL pertaining to below sternum SUPRACLAVICULAR pertaining to above clavicle

36. Joints – more in Ch 9 • Articulators – like the bus…. • Suture joint – immovable, no cartilage • Pubic symphysis and intervertebral joints - slightly moveable with fibrocartilagenous disks. • Synovial p411– fully moveable – joins bones with articulating cartilage, a meniscus maybe (like in knee), ligaments, synovial membrane and synovial fluid, and a joint capsule. • Either hinge action, or ball and socket.

37. general medical terms • ischiopubic pertaining to ischium and pubis • lumbosacral pertaining to lower back or lumbar region and sacrum • osteoblast immature bone or bone cells • osteocyte mature bone cell

38. Osteocytes are mature, nondividing bone cells – they come from immature osteoblasts – cells that build new bone Osteoclasts – cells that break down old bone osteoblast = immature bone or bone cellsosteocyte = mature bone cell

39. Dz, disorders avascular necrosis - death of epiphyseal cells (if in femur, as it usually is, it’s called Avascular Necrosis of the Femoral Epiphysis – proximal is assumed) – blood supply interruption chondromalacia softening of cartilage herniated disk intervertebral disk protrudes between vertebrae to some degree and puts pressure on spinal nerve root; commonly called slipped disk myeloma tumor originating from bone marrow chondroma tumor originating in cartilage -benign

40. The whole ‘ankylo’/‘spondylo’ thing Ankylo = just means ‘Stiff’ so Ankylosis = just means stiffness of a joint Spondylo = just means ‘Vertebra’ so Spondylosis just means condition of Vertebrae -itis = inflammation of , so now what about this one? Ankylosing spondylitis = inflammation of the vertebrae with stiffness aka Rheumatoid Arthritis (RA) of the spine (an old-fashioned term) SPONDYLOARTHROPATHY - what?

41. Spondylolitheses or Spondylolisthesis = ‘slipping vertebra’ -- pathological fx (compression) or injury cause vertebra to ‘slip’ anteriorly over another vertebra Big owie

42. Osteo – bone Osseous – pertaining to boney tissue • Ossification - process of bone formation, cartilage becomes bone or bone-like tissue. • Thus, ossified tissue is invaginated with blood vessels, bringing minerals like calcium. (Remember those epiphysial plates?) • Bone formation is a dynamic process; • Bone remodeling continues throughout life.

43. How do we repair? We don’t, unless ROM is limited, or nsaids don’t help Extra Corporeal Shock Wave Therapy is one tx - Surgery is another Osteophytes - Osteophytes are bone spurs- form along joints -seen in arthritis, areas of wear. Largely responsible for limitation of joint motion, pain. Why? Body tries to increase joint surface area to better distribute weight across damaged joint surface. Unfortunately, a largely wasted effort, as bone spur increases restriction and pain.

44. Osteotomy – to make an incision into a bone osteitis inflammation of bone osteochondritis inflammation of bone and cartilage osteoclasis surgical fracture of a bone: surgical destruction of bone tissue, perhaps to reconstruct a malformed bone, or improperly healed bone. osteofibroma tumor of bony and fibrous tissues osteomalacia softening of bone Osteolysis breaking down of bone tissue osteomyelitis inflammation of bone and bone marrow osteoma tumor originating in bone – benign osteosarcoma tumor of bone – malignant Aka Osteogenic sarcoma (think of ‘genesis’) Ewing’s sarcoma tumor of bone –malignant also, but occurring in young males Remember - ‘oma’ just means ‘tumor’ until you know more. ‘sarco’ means you know more! Osteos

45. Osteitis deformans • Osteitis deformans AKA Paget's disease of bone, bone metastasis (with/without hypercalcemia) • Chronic disorder – Excessive breakdown/ formation of bone tissue that occurs causes weakened bone, bone pain, arthritis, deformities, and fracture. • Viral, may have hereditary factor, rare in women, rare in men younger than 40

46. Pathological fractures… • Underlying disorder or disease (such as infection, osteoporosis, noncancerous bone tumor,or cancer) weakens bone, leading to fracture • Patient with breast cancer metastasized to bone. • Note proximal femoral bone on left side of image looks thinner than on right side. • This femoral pathological fx is due to metastasis of breast cancer.

47. Osteoporosis - decreased bone density/ loss of bone massGuess which is normal and which is osteoporotic?

48. Simple/Closed -Skin is not torn –fx contained within the tissue Complicated/Compound/Open-Skin, soft tissue, periosteum are torn; dirt, debris, or bacteria can easily contaminate wound/bone itself AND************************** Displaced fx -broken ends of bones are separated or bent at an angle Nondisplacedfx -bone’s normal shape and alignment is maintained despite fx completely through bone Fractures – 2 things

49. Avulsion Small fragments of bone detach from where tendons or ligaments attach to bones; usually affect hand, foot, ankle, knee, shoulder If intra-articular; leads to loss of motion and onset of osteoarthritis http://orthopedics.about.com/cs/brokenbones/a/compression.htm

50. Displaced fx -broken ends of bones are separated or bent at an angle Nondisplaced fx – bone’s normal shape and alignment is maintained despite cracks completely through bone Stress fx - bone becomes stressed repeatedly over time because of certain activities, such as walking with a heavy pack or running Occult fx -difficult or impossible for a doctor to see on initial x-ray; may appear as dark or white lines days to weeks after injury Growth plate fx -Break through growth plate may cause bone to stop growing/grow crookedly in children Cracked, broken, smushed