Transcribed by Sarah Sinisgalli [Basic Tissues] [Lecture #15] - [Bone Part I] by [Dr.

Wishe]

1/30/2014

[Slide #1] -[2014 Bone I] [Dr. Wishe] The clock just turned 8:00 so we might as well get started. Last period, I had spoken about different types of cartilage, hyaline being the major form, elastic and fibrocartilage (much more limited in extent). Just a few words to conclude the cartilage portion, we did briefly discuss cartilage growth just let me review that a little bit because its important in terms of bone development. Hyaline cartilage grows in two different fashions, from within, and without. So if this were a piece of hyaline cartilage, growth on the outside occurs here, through a structure called a perichondrium. Perichondrium have a fibrous layer and a chondrogenic layer. From the chondrogenic layer, chondroblasts developed and chondroblasts went into a synthesizing mode, and produce cartilage matrix. And once that happens, the matrix deposited all around the cell. And one this happens, the chondroblast changes its name and its called a chondrocyte. And a chondrocyte exists in a space called a lacunar. And this is all happening from the outside via the perichondrium. This is what is referred to as appositional growth. You are adding on from the outside. The other type of growth occurs internally. I showed you isogenous groups of chondrocytes. One cell became 4, 4 went up to 8. Somewhere in that group of 8, one of those cells was the parent cell. And the fact that this is happening internally, this leads to an increase in the length of the cartilage. That process is called interstitial growth: growth from within. So thats how cartilage increases in terms of size. You are going to find a similar situation in terms of bone, but how this growth occurs is a bit different. When we get to bone formation, we will discuss it at that point of time. The fact that cartilage has no blood vessels makes it a great tissue for transplantation. Yes, there are blood vessels outside the cartilage, and nutrients and oxygen diffuse in but there are actually no blood vessels in the cartilage per se. And So [when] an immune response against a piece of transplanted cartilage does not take place, whereas when you transplant the kidney, or a piece of the liver, each of those organs does have blood vessels and the presence of the blood vessels does lead to an immune response and thats why anybody who has transplants has to take special medication to suppress the immune system. If you have too much of one thing or too little of one thing, you get a whole different complex of reactions occurring. So if you are short of proteins or Vitamin A, youll find that the epiphyseal plate or disc in your long bones isnt as well developed, it is reduced amount. If we take the opposite, too much, say, of Vitamin A, you are going to have an increase in thickness of the epiphyseal plate, increased bone formation, increased ossification. Everybody has heard of Vitamin C, ascorbic acid, and Im sure in Building Blocks, they must have spoken about Scurvy. Im not sure if Dr. Li in her CT lectures mentioned Scurvy. But Scurvy comes about from a shortage of Vitamin C, and Vitamin C is important to the development of Collagen. Youre short of it, youre going to have a problem in the formation of Collagen, and scurvy is at least a condition that can be corrected. If you go back to the old time sailors, on those old ships, they were out of port for months at a time, they ran out of their fruits and

vegetables on board, and a lot of the sailors came down with Scurvy. Then they pulled into a new island, stocked up fresh on fruits and veggies, the Scurvy disappeared. Vitamin D is important in terms of bone. If youre short of Vitamin D, children can get rickets or adults can get a condition known as Osteomalacia. Theyre actually the same condition, but one affects children, one affects the adults. So you need a certain amount of Vitamin D to get a proper amount of calcium in the body. If youre short of Vitamin D, the calcium and even the phosphorous levels are too low, and thats going to affect calcification of the bone, and the bone is not going to be as strong as it should be. Another important hormone, a growth hormone, somatotropin, is produced by the pituitary, as well as thyroxin, produced by the thyroid gland. As I had mentioned last time, I consider them as motherhood hormones. They are needed for the development of the entire body. If theyre short an amount or concentration, this is going to decrease the amount of cartilage growth that takes place if you have a decrease in cartilage growth, this will seriously affect bone growth. Particularly in endochondral bone formation. So that actually finished the cartilage material, and now were ready to go on to bone. [Slide #2] [Joints] [Dr. Wishe] Heres our first official picture. And Ive decided to talk about joints first. They could have come at the end of the lecture. Everybody does their own thing. In essence, there are two types of joints. They are shown in red. Synarthrosis, and Diarthrosis. Synarthrosis type of joint has a very limited mobility or motion or no movement at all. Whereas, the diarthroses are freely movable joints. Under the synarthrosis, there are several different types of joints, and as you look at the anatomy textbooks, one from the other, they all do things a little differently. So, we cant go too wrong with this classification system that Ive listed. The first one, synostosis, youve already been exposed to and that refers to the skull. The bony sutures, irregular in nature, that join the various skull bones together: the two parietals, the frontal. So every pair of bones with full growth and development are permanently joined together. When you start developing, there are sutures, but they are connective tissue sutures, and that gives the skull a certain amount of flexibility, particularly with development of the brain. When the brain is fully developed, it sends out signals such that the soft tissue connective tissue sutures disappear ad now you have your hard, bony sutures. So again, were dealing with something, which has virtually no movement. Synchondrosis, as you look at the word, you see chondro. That immediately should trigger off a response to you, were referring to cartilage. Whenever you see the prefix chondro. So hyaline cartilage is involved in this type of joint. A good example would be the costocartilages and you have the ribs attached to the sternum, not bone to bone, but rib, hyaline cartilage, sternum. Of course, the last couple of ribs are a little different. There are two pairs of free ribs, and a couple of pairs of floating ribs. They do not directly attach to the sternum via the cartilage. The next example, Syndesmosis, this is where bones are attached via a softer type of tissue, and the example would be like the pubic symphisis. This has also very little movement, but in terms of the female pregnancy and all, it does permit a slight degree of motion. So, as the baby gets larger and larger, there is a bit of flexibility that does exist. Also you will find this type of joint associated with the

ulna and the radius, and the tibia and fibula. Finally, the last example, Im sure youve heard of by this time, this is associated with the PDL attaching alveolar bone to your cementum. Again, very limited motion, the type of motion that exists here is more of an absorption, a shock absorber, if you will. Of course as youre performing your mastication functions, you are subjecting the region to a lot of wear and tear and the PDL is literally absorbing the shock effects. In the process of doing it, there is a slight degree of movement, but not a heck of a lot. And then we come to the diarthrosis freely movable, and of course this is characteristic of your long bones. The entire joint is surrounded by a fibrous joint capsule. Its like youre wearing a coat on your body. It encloses the two articulating ends of the bone. And then part of the capsule, the inner layer, the synovial layer, we use the word synovial membrane, it doesnt matter what you want to call it, is a thin layer special cells called synoviocytes, and these cells produce the synovial fluid which goes into the synovial cavity. So each of these joints is cushioned and protected by your synovial fluid. Years ago, I used to exercise in the gym, and youre probably looking at me now saying nah, he never did that, and the piece of equipment that I loved was the leg press. Some of you may know what that is and some of you may not. Its a machine that youre pushing something with your legs, and you can add on weights. So yours truly did make it up to pushing 400 pounds, believe it or not. Why do I tell you this story? After doing this years and years, all of a sudden, my knees started to bother me, and the knees swelled up. So I went to an orthopedic person, and you have to be careful what doctor you use. As soon as the doctor mentions surgery, you go get a second and third opinion. That should be part of your vocabulary. You just dont accept one opinion. And he told me that my cartilage, the articulating cartilage, was cracked and even the cartilage dealing with the patella had a problem. Ok, so out comes this big syringe, with a big needle, and he sucks the fluid out. Anybody know how much fluid there should be, say, in the knee joint? Probably not. Maybe 3 mL, well push it to 5. I had 75 mL of fluid in there. Recently, my son went through a problem, he had 150 mL in the knee joint. So something obviously is wrong. I went back two weeks later, another 50 mL came out. Then they resort to a more aggressive treatment. Theyll give you a cortisone shot, together with some novocaine, reduces the pain. Finally a month later, I was back again, were getting less and less fluid, 25 mL came out. He said next time this happens, were off to surgery. That was when I got some other opinions. The second orthopedic chaps aid I have no idea whats wrong with you. Uh, you got an x-ray but did you have an MRI done? I said no. So that was my next job, to get the MRI done. So that came back, and he said theres nothing wrong with your cartilage, theres no fracture. Lets say that cartilage is supposed to be this thick, mine was that thick. So what happened, playing the macho role, pushing 400 pounds, I literally round down the cartilage, and wore it thin. And I spoke about hyaline cartilage, particularly at the articulating end of the long bones, what it does. A lot of the water which is bound to the GAG molecules, is loosely bound, so you get involved n exercise, the water is released, they give you more synovial fluid. But when you wear down that cartilage, you dont have that water to contribute to the synovial fluid. The tissues come closer together, they tend to rub, and thats going to give you inflammation, excess fluid production, that always goes with inflammation, thats your edema, and you have problems. So

you have to be careful what youre doing, moderation is always a good term to follow. Yes, you could have surgery. They could inject your knee, which is kind of painful. Ive had injections in the back, when the needle goes in you just about reach the ceiling, and then you get used to it, and you calm down. Or you could take a less aggressive approach by taking Glucosamine Chondroitin Sulfate. And thats nothing more than a lubricant. And that lubricates the synovial joint of the knee. Its highly controversial, but I found that by taking a name brand, like Cosamin DS, my knees felt great. When I took the generic brand, it wasnt helping as much. So thats why this particular medication is sort of controversial, but it has helped me, and whomever I recommend it to, it has helped. And its only over the counter. Bottle of 240 in the city used to run me 100-125 dollars. Costcos normal price is about 60. And sometimes they have a sale, 12 dollars off. No one appreciates my tips for the day. Oh well. [Slide #3] [G&H Atlas Plate 4-5 Fig. 1 Endochondral Bone Formation] [Dr. Wishe] - Moving along, heres a picture of a typical synovial joint. One articulating surface, your second articulating surface, and your light pinkish tissue happens to be hyaline cartilage, its the articulating cartilage. As we look at the bottom bone, you will see something happening here, with the secondary sign, so youre getting the development of the epiphyseal region, and separating the articulating cartilage is the secondary bone, and on the other side, is your epiphyseal disc or plate. As long as this structure is present, you can continue to have growth in the long bone, the lymph. Once the epiphyseal disc disappears, that ends secondary growth. And youll see part of the bone here, youll see the letter [D], that stands for diaphysis. And this is sort of misplaced, the M, that stands for metaphysis. Actually, between the epiphysis and the diaphysis, is your metaphysis. Its a triangular, a funnel shaped region. The epiphysis, the metaphysis and the diaphysis have a marrow cavity filled with bone marrow. And even at this stage of development, you can see some bone developing here, a little more jumbled up on this side, and thats the formation of your bone column, which turns out to form the compact bone of a long bone. The more central cavity, youll have spongy bone forming, in between the little pieces of spongy bone, youll have a lot of bone forming cells, giving rise to the white and the red types of cells. And external to that, this pink layer here represents the periosteum, which is like a perichondrium. Instead of being chondrogenic in nature, its osteogenic in nature. [Slide #4] [J. (Mescher, ed.) Fig. 8-19] [Dr. Wishe] This diagrammatic representation is pretty good. This comes from a textbook by John Kerrer (?), and by the way you can link into John Kerrer, its online. One bone, second bone, each bone has an epiphyseal disc. This represents your epiphysis, metaphysis, and finally down here, the diaphysis. And part of the bone marrow changes from red to yellow. And just incase I forget to mention it during the course of the lectures, the bone marrow can go back and forth, red could become yellow, tallow could become red, depending on the scenario. And here is your periosteum; its enclosing the two bones. It has an outer fibrous layer, and you can see this little purple layer, thats your inner layer, your synovial layer, or your

synovial membrane, and the space represents the synovial cavity. Below is an actual picture of two bones, essentially showing you the same thing that we saw in the picture above. Again, the epiphyseal disc, the epiphysis and the diaphysis down there. [Slide #5] [Functions of Bone] [Dr. Wishe] - Most of you, not every one of you, should know functions of bone, not necessarily every bloody detail, but you should have an idea. And the first function is support. In anatomy, Im sure you picked up bones, theyre pretty lightweight. If you took all of the bony material in the body and weighed it, compared it to the weight of the rest of the body, it doesnt weigh much and so this material is supporting the whole weight of the body. Its pretty strong. It has a lot of tensile strength, compressive strength, so its a pretty decent supporting material. Muscle attachment. Your skeletal muscle and bone form a system referred to as your leverage system, and because of your system, youre able to move. Whether its walking, swimming, jumping, it doesnt mater. So this is involved in locomotion. Protective, important function. If you look at the skull, the skull is protecting the underlying brain. Look at the ribcage, its protecting the underlying thoracic cavity. But you have to be careful with this. The ribs, although theyre serving a protective function, arent really that strong. You could be doing simple riding a bicycle, you lose control of the bicycle, you crash into a fence or a wall, and you hit the ribcage. Well those ribs can fracture and break, and a fractured end of a rib is kind of sharp. It can lacerate the underlying liver. You could bleed to death. So, protective, yes. But you have to take that with a grain of salt. And then, each and every bone that has bone marrow in it, the bone, as a tissue, is protecting the bone marrow. So there are a number of different types of protective functions. Metabolic. So you know this is going to have something to do with the internal workings of the body. And two important ingredients that you find in bone are calcium and phosphorous. So 99% of the total calcium in the body will be found in bone. And 85% of the total phosphorous will also be found in the bone. These items can be mobilized, and when you break down bone, youre mobilizing these particular ingredients. And breakdown of bone could occur slowly or quickly. If its rapid, its more or less of a physical type mechanism, with a calcium from the hydroxyapatite crystals just enter into the interstitial fluid, which then becomes part of the blood. Its a physical mechanism. But if mobilization of calcium is slow, you go through a rather complex process. Two organs in the body are important, parathyroid gland and the thyroid gland. Parathyroid gland reacts immediately when the level of calcium in the body drops. And it releases a hormone called PTH (parathyroid hormone, parathormone, either term is acceptable). And as a result, this eventually will have a stimulating effect and lead to the formation and appearance of a special cell called an osteoclast. Dr. Li spoke about macrophages and foreign body giant cells. The osteoclast is nothing more than a foreign body giant cell. There are odontoclasts, cementoclasts, they are all the same cell, but they are going to be breaking down different tissues to release the calcium. Once enough calcium has been released into the body, theres a mechanism to shut down this

process. This process, by the way, is called bone resorption. Youre breaking down the bone, youre resorbing the bone, and now the calcium is entering into the circulation. And wno the thyroid gland comes into play, and it releases something called calcitonin, and also known as thyrocalcitonin, so this comes from your parafollicular cells, which youll learn about in Craniofacial Biology, which develop from the branchial apparatus. This inhibits bone resorption, shuts it down. So there is a special equilibrium existing between these two organs, between the osteoclasts, and the osteoblasts. And once bone is changed, we use the process remodeling, bone is being remodeled, bone breaks down, and new bone is formed. Well have a discussion on bone remodeling later on. Another function, hematopoietic. I know I already alluded to that, where your bone marrow is important in the formation of red and white blood cells. Bone is a self-repairing tissue, its very dynamic. There is no other tissue in the body like it. Youll notice what I wrote down: constant renewal and remodeling. As you get older, the bone gets weaker. What does the body do? It remodels the bone. It gets rid of the weaker bone, and deposits new stronger bone. Think of a rock hitting a car windshield. You get a little crack. Whats going to happen in time? Thats going to spread throughout the windshield, and youll have to replace it. Its like a micro facture. Well thats exactly whats happening with the bone remodeling. Youre getting rid of weak bone, bone with micro factures, etc And lets jump to the very last item, ARF sequence. This is a sequence thats involved in remodeling a bone. A stands for activation, R for bone resorption, and F for bone formation. When we talk about that, I use a slightly different abbreviation, I throw a couple of additional letters in and youll see why I do that at that time. Distraction Osteogenesis. Important role for your orthodontist. [Slide #6] [Proffit Fig. 2-44 Distraction Osteogenesis] [Dr. Wishe] One of the reference books is an orthodontics book by Proffit, and this is a perfect example of Distraction Osteognesis. Youll see the device that this child is wearing bilaterally, and thats involved in the process of Distraction Osteogenesis. Look at the top picture. The face looks fairly normal, the problem that youre seeing is involving the lips. Theyre sort of offset, it doesnt look normal, and what you may have difficulty seeing, is that this part of the mandible is projecting out. This part of the mandible doesnt project out that far. So, youre having this type of scenario. So both sides of the mandible did not grow evenly. This can be fixed. What one does, you can do it unilaterally or bilaterally. You would do a little incision, and actually fracture the mandible. What happens when you get a bone fracture any place? It heals. So the fracture site will form new bone, and rejoin up. But this device is literally screwed into the bone, and they know how much bone grows on a daily basis. So as the fracture site fills in with bone and becomes close to touching each other, you turn the screw, pulling the bone apart again. And this procedure is repeated until this side of the mandible has grown sufficiently to match the other side of the mandible. So it looks like a complex gizmo, but there are screws in here to make those adjustments. [Slide #7] [Proffit Fig. 19-2 Distraction Osteogenesis]

[Dr. Wishe] -And here you have two mandibles. Obviously, this is the fracture sites. And theres another fracture site. Diagram B shows at the fracture site the two parts of the bone pulled apart. You see the same thing over here. So it will heal, and get pulled apart again. [Slide #8] [Proffit Fig. 19-16 Distraction Osteogenesis] [Dr. Wishe] And heres an actual individual, adult, who has this procedure being done. Her face is literally lopsided. So the mouth is off kilter, the nose may be slightly affected but not too bad, but something has happened up here as well. So the eye has become slightly affected. Look at this picture, and look at picture F. Two different people. Picture F shows you now an attractive woman, picture A doesnt do that. So before and after treatment. Picture B is a cast and you can see right overe here that thi sia prt of the gizmo and they have it attached to two different parts of the bone, and inbetween is a fracture, and here is an actual picture of this gizmo screwed into the mandibular bone. And here we have some xrays where you can see the gizmo, and theres also something happening in the mid-mandible here because theres another device, and theres something ahpepnign up here as well. This whole business of Distraction Osteogenesis did not start with the oral cavity, but with the lower limbs. As a means of making the lower limb longer, youre lengthening the leg bones, and this would add on height to the individual. And eventually it made its way into dentistry. [Slide #9] [J (Mescher, ed.) Fig. 8-14 Endochondral Bone Formation] [Dr. Wishe] We can classify bones different way. There are long bones, short bones, flat bones, irregular shaped bones, sesamoid bones. Long bones, your typical ones, humerus as an example, and femur. A short bone is a bone that youll find, sort of in this part of the hand, the carpals, or the feet, the tarsal type bones. And flat bones, you definitely know, these are all the bones of the skull like your parietal and frontal bones. Irregular shaped bones, I dont know how they covered bones in terms of anatomy, but if you look at the skull, particularly the sphenoid and the ethmoid bone. These dont follow any particular pattern, so they fit into the category referred to as irregular shaped bones. And by the way, the sphenoid is derived from three pairs of cartilages so its a pretty large bone, in terms of the skull per se. Sesamoid bones are tiny little bones that may develop in tendons or ligaments and it tends to increase mechanical strength involved in those areas. Not many people talk about this type of bone. To look at the gross macroscopic structure of bone, were going to use these diagrams which really illustrate endochondral bone formation, but Im using this last picture for this part of the discussion. The ends of the bone are somewhat round in nature, and thats the epiphyseal portions, the wider spherical ends. Most of the bone, thats this region here, that makes up the diaphysis. Its really a shaft, its like a cylindrical tube. And so in between joining these two areas up here, would be your metaphysis. Thats your funnel shape, bone shaped region, sort of like a transition type of zone. And if the bone hasnt fully developed yet, you will find this structure, thats the epiphyseal plate or disc. Once the plate or disc disappears, secondary growth, growth of the length of the bone terminates, and it cannot be restarted. There are two types of bones, theres really three, but well

leave it at two right now, and you can see them on the picture. Compact bone, thats this part of the bone, its really making up the shaft of the bone. Its also known as dense bone, haversian bone, [or] cortical bone. And then in the marrow cavity, the medullary cavity, youll find spongy bone, and spongy bone resembles your household sponge. You maybe never paid too much attention to it, but you have little pieces of sponge with holes. Well the little pieces of sponge represent your bone tissue, thats the spongy bone. The holes represent where you would find your bone marrow. And spongy bone is also known as cancellous bone, and trabecular bone. Some books use the term called lamellar bone, which I dont like because lamellar bone isnt technically compact and spongy so its not a proper descriptive type of term. The end of the bone, this blue region, is all hyaline cartilage, thats all your articulating end. And yes, we do have perichondrium surrounding the cartilage, but not at the articulating end. If you had perichondrium or periosteum surrounding it, that would not make for a good articulating surface. The cartilage is sort of on the wet side, if you will. Dont forget, it will release water. Theyre sort of greasing the joint, allowing the bones to move around much more easily. Thats why the cartilage is present. We could use two different terms to describe where we are. The outside of the bone is called a periosteal surface, the inside of the surface, the endosteal surface. And as a result, were going to get two different types of connective tissue layers. Along the periosteal surface, youre going to get something called the periosteum, which is like the perichondrium. It is a two-layered structure: the outer layer is fibrous, the inner layer is osteogenic. With regard to the endosteum, its going to line the entire internal surface of the bone, and if were going to look at spongy bone, heres a little bone, trabecula in the bone marrow area. This entire trabecula of bone has endosteum around it. As part of compact bone, the functional system is called an osteon. The osteon has a central cavity, haversian canal, thats lined by endosteum. So, the endosteum will line all internal surfaces. When we talk about the skull, the flat bones, in essence, its a sandwich. Heres your two slices of bread, compact bone, in between here is your cream cheese or salami, whatever you want to put in, thats your spongy bone. So the organization is similar but different. When we compare compact and spongy bone, they look different they serve different functions but theyre both bone containing the same types of cells. Cortical bone, the dense bone, haversian bone, has strictly a protective type of function. If you were to separate all this cortical bone from the body from say a femur or something, it would account for roughly 75-80% of the weight of the bone. That means the rest is your spongy bone. Now you look at the bone, you say hey, most of the bone seems to be made up of spongy bone, so by volume, spongy bone far exceeds the compact bone. But in terms of how much of the bone is compact, how much of the bone is spongy by weight, compact bone way out beats everything. [Slide # 10] [G&H Text Fig. 7-15 Bone Formation Endochondral] [Dr. Wishe] -And this is just another picture again from your text showing the epiphysis, the epiphyseal disc or plate, and your diaphysis. [Slide #11] [N-TC Fig. 6-2]

[Dr. Wishe] - Heres a nice picture of a bone, this has to be compact bone. There should be discussion about this at all. Look at the density. Now look internally. You see these little tiny wisps of bone thats the spongy bone. And all the spaces then represent where you have your bone marrow. Here we see a little part of the apex of a tooth. Do you think that this is the maxilla or the mandible? It is the mandible. And how do you tell that? By the amount of compact bone. As you go around the mandible, thats where the compact bone is. You dont have any arrangement like this in the maxilla. [Slide #12] [Gross Structure of Long Bone] [Dr. Wishe] - So in terms of gross structure, we have epiphysis, metaphysis, diaphysis, bone types, compact/spongy, and I have not mentioned woven bone yet. Whenever bone forms, its going to form woven bone first. And woven bone is a weak bone, its formed rapidly. Woven bone will then be converted into your mature spongy bone, and some of the mature spongy bone will then become compact bone. And we spoke about the periosteal and endosteal surfaces.