ANATOMY AND PHYSIOLOGY

There are 5 main bone types in the human skeleton. Long bones, short bones, flat bones,
irregular bones and sesamoid bones.  A sixth type known as “Wormian” bones is also found,
which are found during growth of the skull in children,

 long bones are the main lever arms of the appendecular skeleton, such bones are the
femur, humerous and (Despite their relative length) the phalanges in the finger.
 Short bones are very strong and are very good at resisting deformation through shock. 
As such, they are found in the wrist and foot (Carpals and Tarsals respectively) as this is
where the loads on the body are normally applied, through  walking, running, or lifting
and throwing.
 Flat bones are, as their name describes, relatively flat.  They provide protection for
organs, and offer attachment points for muscles.  These are found on the body as the
Skull, pelvis and sternum.
 Irregular bones are not specific to any one function, and are found in a variety of roles
within our bodies,  they are found in the face, but probably more importantly, in the
spinal column.
 sesamoid bones are small and oval, and are located within tendons to aid its motion
around a joint, the obvious of these being the knee-cap, or patella.

These varieties in size and shape are all due to the different functions these bones carry
out.    However, they all follow a similar structure, a variation on a theme.  They must all be
strong enough to support us, and light-weight enough so we can move.  This is achieved by
having the hardest area of bone, called compact bone, on the outside, forming a rigid cylinder
called the Diaphysis, and looser, spongy tissue, known as cancellous bone inside the head. 
Between the cancellous bone and the interior of the shaft, or Medullar cavity, are plates.  These
Epiphyseal plates are part of the development process of the bone, and are discussed in more
detail later.

Within the medullar cavity is yellow bone marrow.  This is where vital minerals, and
calcium are stored.  Red marrow is found within the cancellous bone at each end, and this
manufactures red blood cells.  On the very outside of the bone is found the periosteum.  This is
a protective layer round the bones, that provides the attachment for ligaments and tendons.  At
the point of contact with other bones is found Articular cartilage.  This provides a frictionless,
cushioning coating to prevent the bones from wearing each other away.  Failure of the cartilage
is what causes arthritis.

Skeletal Development

In the fetus, the skeleton is first laid down as cartilage, but as development continues, it
is replaced by bone in  a process known as ossification.  This is a complex process involving the
gradual removal of cartilage by cells from outside which invade it; other cells of a different kind
then follow and lay down the bone which eventually replaces the cartilage that has been
removed.

In an X-ray of a bone, it is possible to see where cartilage is still present (At the
Epiphyseal plates),  these are the places where growth in length is still taking place, and it is
possible to estimate a child’s age from the size of these regions.

Because children have a greater percentage of cartilage in their bones than adults, their
bone structure is significantly more flexible than adults.  This means that, in the event of a
fracture, the bone will bend and splinter, rather than snap.  In the case of exercise and sport, the
bones must not be over loaded, or else longitudinal growth may be reduced, resulting in pain,
and stunted growth in later life.  Weight training should not be carried out by children until their
development has slowed.  It is not the age, or size of the child that is important, rather than their
developmental stage.

Synovial Joints.

At any point in the body, where two bones meet, there will be a joint of sorts.  The most
common joint is the Synovial joint.  These joints are freely moving, and allow efficient transfer of
muscular force from one muscle to bone  and to bone.
There are a number of different types of Synovial joint, these are typically...

 Ball and Socket: For example, at the femur-hip interface. This is where the head of the
bone fits into a socket on the other bone, allowing a wise range of motion, in a number of
axes.
  Hinge joints: As their name indicates, these joints provide movement in one plane, like a
door hinge.  Found at the join between humerous and ulna (loosely speaking)
  Pivot joints:  These allow rotation of one bone around another, such as where the radius
and the ulna meet.
 Condyliond:   Also known as Ellipsoid joints, this is where curved facia meet, offering
movement in a number of planes. Found in the fingers.
 Gliding joints: Found between two flat parts of bone, and allow little lateral movement
only.  Found between the Carpals in the hands.
 Saddle joints:  These joints allow a greater range of movement than condyloid joints, yet
are similar in shape, the most well known example is at the base of the thumb.

The ends of the bones in Synovial joints are shaped to fit each other in such a way as to
limit their movement in the directions required.  Range and direction of movement is aided and
controlled by ligaments that attach the bones together.  On the surface of the bone is the
Articular cartilage, which aids movement, and reduces wear on the bone face.  Surrounding the
whole joint is the “Joint Capsule”.  This contributes to the control and stability of the joint, along
with the ligaments.  It is attached to the periosteum, tough and stretch resistant. Within this
capsule is the Synovial membrane from which the joint gets its name.  This secretes Synovial
fluid into the joint, which aids in reducing friction.  Between tendons and bone, in certain joints,
little pads known as bursae can be found.  These offer a “bridge” for the tendon to move over,
reducing friction and wear between the tendon and the bone itself.

As was mentioned in the description of the structure of the joint, the shape of fit of the
bones and the tendons restrict mobility of the joint to within required constraints.  There are a
number of other factors that also affect the range of motion, or ROM, of a joint.  The most
obvious restrictions are structural, bony protrusions around the joint, like where the point of the
elbow fouls the humerous, limiting its movement.  The joint structure itself, with the ligaments,
joint capsule and face of bones.

Temperature plays a major role in ROM.  Quite simply, the warmer the joint is, the
greater its ROM will be, this places great emphasis on doing a proper warm-up before exercise. 
Stretching is important to athletes.  This is because as muscles become more and more trained,
they tend to shorten slightly, thus restricting mobility.  However, good muscle structure also add
to the stability of many joints, like the knee.  As we age, our body’s ability to function
decreases.  this includes flexibility.  Older people don’t have the same strength as the young.
 Individual bone structure

Compact bone or (Cortical bone)

The hard outer layer of bones is composed of compact bone tissue, so-called due to its
minimal gaps and spaces. This tissue gives bones their smooth, white, and solid appearance,
and accounts for 80% of the total bone mass of an adult skeleton. Compact bone may also be
referred to as dense bone.

Trabecular bone

Filling the interior of the organ is the trabecular bone tissue (an open cell porous
network also called cancellous or spongy bone), which is composed of a network of rod- and
plate-like elements that make the overall organ lighter and allowing room for blood vessels and
marrow. Trabecular bone accounts for the remaining 20% of total bone mass but has nearly ten
times the surface area of compact bone.

Cellular structure

There are several types of cells constituting the bone;

  Osteoblasts are mononucleate bone-forming cells that descend from osteoprogenitor
cells. They are located on the surface of osteoid seams and make a protein mixture
known as osteoid, which mineralizes to become bone. Osteoid is primarily composed of
Type I collagen. Osteoblasts also manufacture hormones, such as prostaglandins, to
act on the bone itself. They robustly produce alkaline phosphatase, an enzyme that
has a role in the mineralisation of bone, as well as many matrix proteins. Osteoblasts
are the immature bone cells.

 Bone lining cells are essentially inactive osteoblasts. They cover all of the available bone
surface and function as a barrier for certain ions.
 Osteocytes originate from osteoblasts that have migrated into and become trapped and
surrounded by bone matrix that they themselves produce. The spaces they occupy are
known as lacunae. Osteocytes have many processes that reach out to meet osteoblasts
and other osteocytes probably for the purposes of communication. Their functions
include to varying degrees: formation of bone, matrix maintenance and calcium
homeostasis. They have also been shown to act as mechano-sensory receptors—
regulating the bone's response to stress and mechanical load. They are mature bone
cells.

 Osteoclasts are the cells responsible for bone resorption (remodeling of bone to
reduce its volume). Osteoclasts are large, multinucleated cells located on bone surfaces
in what are called Howship's lacunae or resorption pits. These lacunae, or resorption
pits, are left behind after the breakdown of the bone surface. Because the osteoclasts
are derived from a monocyte stem-cell lineage, they are equipped with phagocytic like
mechanisms similar to circulating macrophages. Osteoclasts mature and/or migrate to
discrete bone surfaces. Upon arrival, active enzymes, such as tartrate resistant acid
phosphatase, are secreted against the mineral substrate.

Formation

The formation of bone during the fetal stage of development occurs by two processes:
Intramembranous ossification and endochondral ossification.
 Intramembranous ossification mainly occurs during formation of the flat bones of the
skull; the bone is formed from mesenchyme tissue. The steps in intramembranous ossification
are:

1. Development of ossification center

2. Calcification
3. Formation of trabeculae
4. Development of periosteum

Endochondrial ossification

Endochondral ossification, on the other hand, occurs in long bones, such as limbs; the
bone is formed from cartilage. The steps in endochondral ossification are:

1. Development of cartilage model

2. Growth of cartilage model
3. Development of the primary ossification center
4. Development of the secondary ossification center
5. Formation of articular cartilage and epiphyseal plate

Endochondral ossification begins with points in the cartilage called "primary ossification
centers." They mostly appear during fetal development, though a few short bones begin their
primary ossification after birth. They are responsible for the formation of the diaphyses of long
bones, short bones and certain parts of irregular bones. Secondary ossification occurs after
birth, and forms the epiphyses of long bones and the extremities of irregular and flat bones. The
diaphysis and both epiphyses of a long bone are separated by a growing zone of cartilage (the
epiphyseal plate). When the child reaches skeletal maturity (18 to 25 years of age), all of the
cartilage is replaced by bone, fusing the diaphysis and both epiphyses together (epiphyseal
closure).

Bone marrow

Bone marrow can be found in almost any bone that holds cancellous tissue. In
newborns, all such bones are filled exclusively with red marrow , but as the child ages it is
mostly replaced by yellow, or fatty marrow. In adults, red marrow is mostly found in the marrow
bones of the femur, the ribs, the vertebrae and pelvic bones.

Remodeling

Remodeling or bone turnover is the process of resorption followed by replacement of

bone with little change in shape and occurs throughout a person's life. Osteoblasts and
osteoclasts, coupled together via paracrine cell signalling, are referred to as bone remodeling
units.

Purpose

The purpose of remodeling is to regulate calcium homeostasis, repair micro-damaged

bones (from everyday stress) but also to shape and sculpture the skeleton during growth.

Calcium balance

The process of bone resorption by the osteoclasts releases stored calcium into the
systemic circulation and is an important process in regulating calcium balance. As bone
formation actively fixes circulating calcium in its mineral form, removing it from the bloodstream,
resorption actively unfixes it thereby increasing circulating calcium levels. These processes
occur in tandem at site-specific locations.

Repair

Repeated stress, such as weight-bearing exercise or bone healing, results in the bone
thickening at the points of maximum stress (Wolff's law). It has been hypothesized that this is a
result of bone's piezoelectric properties, which cause bone to generate small electrical
potentials under stress.
 PATHOPHYSIOLOGY

Predisposing factor Precipitating factor

Age (child) vehicular accident

TRAUMA

Skeletal Instability Soft Tissue Injury

Loss of weight support Bleeding

Loss of attachment

Joint motion disabled

Muscle contraction

Inflammatory response vasodilatation

Increase capillary permeability

Protein and granulocytes leak into tissue

Edema

Blood clot at injured site

Granulation tissue invades clots

Reticuloendothelial cells remove debris

Calcium goes into solution

New capillaries grow into clot

New bone cells form

Callus formation
S/Sx : Initial Bruising, dull pain, swelling