Preface
Musculoskeletal system is one of the systems among all system in the body. This
system has a major role in human movement and consists of bones, muscles, joints,
tendons and ligaments including the neurovascular within the system. The knowledge of
musculoskeletal system very useful to determine the normal condition and can be used to
explain pathological concept of many disorders as a whole system. There several diseases
in this system such as development disorders, infections, metabolism, neoplasm and
weakness of muscles. Most of the diseases can be treated as soon as possible through
holistic approach related to medical ethics and informed consent due to patient’s
satisfaction.
Musculoskeletal system is explain the whole body and it's concept as a basic
concept for the other block. That,s why this block is put in advance. Some concept will be
studied again or will be used for the other block.
Musculoskeletal system and disorders will be studied based on case as a trigger.
The case is one of examples of musculoskeletal disorders that are commonly finding the
real situation. It’s needed comprehensive approach to understand this block base on basic
knowledge, clinical and rehabilitation. Hopefully this book will be used as a trigger to study
the core of musculoskeletal system and disorders and can be the basic concept to study the
others especially in special study and special topics.
Best regards
Planners
Introduction
Movement is very important in human life. Everyone should move as an adaptation to the
entire environment even external or internal. Movement is generated by a specific
stimulation. Proper stimulus will be processed through central and peripheral nerves system
and deliver to muscles by axon and neuromuscular junction. The muscle will contract to pull
the bone that is observed as a movement.
To get the optimum movement, there are many aspects should be considered such as
bones, joints, ligaments, tendons, muscles and nerves. They all work together in a complex
coordination to generate a movement according to the stimulus. This guide book will
encourage all the students to comprehend all the topics through lecture, small group
discussion, individual learning, student project and clinical skill. Student should know about
bones and muscles since its developed, location, function and its disorders.
Disorder of musculoskeletal system could be as result of several condition such as
development, metabolism, trauma, infection, degenerative or neoplasm. Any type of
problems will need different approach of treatment such medical, operation, pharmacology
and rehabilitation. Understanding of musculoskeletal can be used in phorensic aspect and
for many purposes. The student comprehends all disorder as in real situation, so this guide
book will provide some cases as a trigger for discussion. So, active participation of student
is the most important aspect in learning by doing process, because all the topics should be
discussed in small group under supervision of facilitator.
Lecturers who give a lecture in the class just give the student the concepts of every topics,
and the student should explore and study insight under guidance of learning task and self
assessment. The succesfull of this block is depending on your active participation in teching
learning process.
See you ….
Contents
1. Preface …………………………………………………………………..1
2. Contents ………………………………………………………………….3
3. Contributors ……………………………………………………………
a. Planners ………………………………………………………….4
b. Lectures ………………………………………………………….4
c. Facilitators ……………………………………………………….5
4. Time Table Regular Class .…………………………………………….6
5. Time Table English Class ………………………………………………6
6. Students Meeting Representatives …………………………………..10
7. Student Project .................................................................................10
8. Assessment ……………………………………………………………..10
9. Learning Programme …………………………………………………..11
10. References ………………………………………………………………63
Team of Musculoskeletal
System and Disorders
~ FACILITATORS ~
Regular Class (Class A)
Venue
No Name Group Departement Phone
(3rd floor)
dr. I Wayan Sugiritama, 3rd floor:
1 1 Histology 08164732743
M.Kes R.3.09
Dr. dr. Bagus Komang 3rd floor:
2 2 Pharmacology 081237166686
Satriyasa, M.Repro R.3.10
dr I Gusti Agung Gede Utara 3rd floor:
3 3 Anasthesi 08123868126
Hartawan, Sp.An, MARS R.3.11
dr. I Nyoman Gede Wardana, 3rd floor:
4 4 Anatomy 087860405625
M.Biomed R.3.12
dr. I Made Dharmadi , MPH 08123804985 3rd floor:
5 5 Public Health
R.3.13
dr. Ketut Wiargitha, Sp.B (K) 3rd floor:
6 6 Surgery 08123804989
Trauma R.3.14
dr. K G Mulyadi Ridia, Sp.OT 3rd floor:
7 7 Orthopaedi 08123972029
(K) R.3.15
Ni Putu Wardani, Sp.An, 3rd floor:
8 8 DME 08113992784
M.Biomed R.3.16
Dr. dr. Made Sudarmaja, 3rd floor:
9 9 Parasitology 08123953945
M.Kes R.3.17
dr. Ni Nyoman Margiani, 3rd floor:
10 10 Radiology 081337401240
Sp.Rad R.3.19
Venue
No Name Group Departement Phone
(3rd floor)
Dr.dr. Ni Nyoman Sri 3rd floor:
1 1 Microbiology 08553711398
Budayanti, Sp.MK(K) R.3.09
dr. Ida Ayu Dewi Wiryanthini, 3rd floor:
2 2 Biochemistry 081239990399
M Biomed R.3.10
dr. Ni Made Susilawati, Sp.S 3rd floor:
3 3 Neurology 08124690137
R.3.11
dr. Ni Made Renny Anggreni 3rd floor:
4 4 Interna 081803651656
Rena , Sp.PD R.3.12
dr. Tjokorda Gde Oka, MS, Clinical 3rd floor:
5 5 081999450045
Sp.PK Pathology R.3.13
dr. I N W Steven Chr, Sp.B 3rd floor:
6 6 Surgery 08123801156
(K) Onk R.3.14
Prof.Dr.dr.I Putu Gede 3rd floor:
7 7 Fisiology 08123811019
Adiatmika, M.Kes R.3.15
Dr.rer.Nat. dr. Ni Nyoman 3rd floor:
8 8 Biochemistry 081337141506
Ayu Dewi, M.Si R.3.16
dr. Firman Parulian 3rd floor:
9 9 Radiology 081337165566
Sitanggang, Sp.Rad(K)RI R.3.17
dr. Ni Made Dewi Dian 3rd floor:
10 10 Interna 08123320380
Sukmawati, Sp.PD R.3.19
Physiology Dept.
(2nd fl)
Joint Laboratory
(4th fl)
Anatomy Dept.
(1st fl)
Histology Dept.
19 Basic Clinical Skill 09.00 – 14.00 09.00 – 14.00
(4th fl)
Team
22/3 Physiology Dept.
(2nd fl)
Joint Laboratory
(4th fl)
20 Mid-Test
09.00 – 10.30
10.30 – 12.00
09.00 – 10.30
10.30 – 12.00
Class Room, Lab,
Team
23/3 SGD
Lecture : Neoplasm Of Bone and Ulcer 08.00 – 09.00 09.00 – 10.00 Class room dr. Eka W
Individual learning 09.00 – 10.30 12.00 – 13.30 - -
21 SGD 10.30 – 12.00 13.30 – 15.00 Discussion room Facilitator
24/3 Break
Self Assessment and Student Project
12.00 – 12.30
12.30 – 14.00
11.30 – 12.00
10.00 – 11.30
-
-
-
-
Plenary 14.00 – 15.00 15.00 – 16.00 Class room dr. Eka W
Lecture : Bone Infections 08.00 – 09.00 09.00 – 10.00 Class room dr. Suryanto Dusak
Individual learning 09.00 – 10.30 12.00 – 13.30 - -
22 SGD 10.30 – 12.00 13.30 – 15.00 Discussion room Facilitator
28/3 Break
Self Assessment and Student Project
12.00 – 12.30
12.30 – 14.00
11.30 – 12.00
10.00 – 11.30
-
-
-
-
Plenary 14.00 – 15.00 15.00 – 16.00 Class room dr. Suryanto Dusak
dr. Tjok Dalem
08.00 – 09.00 09.00 – 10.00 Class room Kurniawan
Lecture : Musculoskeletal Rehabilitation
Individual learning
23 SGD
09.00 – 10.30
10.30 – 12.00
12.00 – 13.30
13.30 – 15.00
-
Discussion room
-
Facilitator
29/3 Break
Self Assessment and Student Project
12.00 – 12.30 11.30 – 12.00 - -
12.30 – 14.00 10.00 – 11.30 - -
Plenary
14.00 – 15.00 15.00 – 16.00 Class room dr. Tjok Dalem
Kurniawan
Lecture : Bone Forensic 08.00 – 09.00 09.00 – 10.00 Class room dr. Alit
Individual learning 09.00 – 10.30 12.00 – 13.30 - -
24 SGD 10.30 – 12.00 13.30 – 15.00 Discussion room Facilitator
30/3 Break
Self Assessment and Student Project
12.00 – 12.30
12.30 – 14.00
11.30 – 12.00
10.00 – 11.30
-
-
-
-
Plenary 14.00 – 15.00 15.00 – 16.00 Class room dr. Alit
Lecture : NSAID And Muscle relaxant 08.00 – 09.00 09.00 – 10.00 Class room dr. Ngurah
Individual learning 09.00 – 10.30 12.00 – 13.30 - -
25 SGD 10.30 – 12.00 13.30 – 15.00 Discussion room Facilitator
31/3 Break
Self Assessment and Student Project
12.00 – 12.30
12.30 – 14.00
11.30 – 12.00
10.00 – 11.30
-
-
-
-
Plenary 14.00 – 15.00 15.00 – 16.00 Class room dr. Ngurah
ATT :
Pre-Evaluation Break : 01 April 2016
EXAMINATION DAY : 04 April 2016
Class Room : R. 3.01 (3rd Floor)
Schedule
Basic Clinical Skill
A 1 – 60
B 11 – 120
C 121 – 148 1 – 32
D 33 – 92
E 93 – 146
Total Student 148 146
ATT :
Pre-Evaluation Break : 01 April 2016
EXAMINATION DAY : 04 April 2016
Class Room : R. 3.01 (3rd Floor)
Assessment
Type of assessment is multiple choice questions (MCQ) and fill the blank and OSCE.
A prerequisite condition to follow the assessment is attendance in at least 75% of all
scheduled teaching-learning activities and follows the questionnaire test during lecture.
Students’ assessment consists of summative assessment that is given at the end of lecture.
Main examination be held at 04 April 2016 and OSCE will be conducted together with other
block at semester IV.
The score main examination will be calculated from questionnaire during lecture (5
%), Basic Clinical Skill (10 %), MCQ (80 %) and SGD (5 %). Passing level is 69.5 or above.
The student who does not pass the passing level should follow remedial. For those student
who get score 64.5 – 69.4 must write paper about musculoskeletal in accordance to
musculoskeletal from SKDI. The student who get score below than or similar to 64.4 must
follow test. Remedial will be held later. Remedial topics are just for the fail topic or not pass.
So, the student must follow the topics that are not yet pass to substitute the main
examination. The best score will be used for final calculation.
LEARNING PROGRAM
Day 1st
MODULE
1
HUMAN MOVEMENT - THE AXIAL SKELETON
Prof. Dr. dr. Mangku Karmaya, M.Repro
AIMS:
LEARNING OUTCOME:
CURRICULUM CONTENTS:
1. Role of musculoskeletal system
2. Element of musculoskeletal system
3. Function of musculoskeletal
4. Development of MSDs
ABSTRACTS:
Musculoskeletal system consists of muscles and bones. Muscles are connected with bones,
cartilages, ligaments and skin either directly or through the intervention of fibrous structures
called tendons or aponeurosis.
Muscles are various in their form, arrangement and size. So there are terms
considering the form as long, broad, short, etc., used in the description of a muscle. The
terms quadrilateral, fusiform, triangular, oblique, penniform, bipeniform, sphincter are
correlate with muscle arrangement. Gastrocnemeus, sartorius and stapedius are terms
according to their size.
Name of the muscles are derived from: (1) their situation, as the Tibialis, Radialis,
Ulnaris, Peroneus; (2) their direction as the Rectus abdominis, Obliqui capitis, Transversalis;
(3) their uses, as Flexors, Extensors, abductors etc. (4) their shape as Deltoid, Rhomboid,
Trapezius; (5) the number of their division as the Biceps, the Triceps; (6) the points of
attachment as the Sternocleidomastoideus, Sternothyroid, Sternothyroid.
It is very important to know the exact origin and insertion because it is of great
importance in the determination of their action. There is a number of actions: flexion,
extention, abduction, adduction, rotation, circumduction, supination, pronation, protrusion
(protraction), retrusion (retraction), elevation and depression. Also the relation of the
muscles especially those in immediate apposition with the larger blood vessels and the
surface marking they produce should be remembered as they form useful guides in the
application of a ligature to those vessels.
The fibrous tisssues are in close relation with the muscle. They are tendons and
aponeurosis. They are connected, on the one hand, with the muscles and, on the other
hand with the movable structures as bones, cartilages and fibrous membranes.
The skeleton of the body is composed of bones and cartilages. Bones provide
protection for vital structures, support for the body, the mechanical basis for movement,
storage for salts (e.g., calcium) and a continuous supply of new blood cells. Cartilage forms
parts of the skeleton where more flexibility is necessary as yhe costal cartilage and articular
cartilage.
There are two types of bones: compact and spongy; its architecture varies according
to function. Compact bone provides strength for weightbearing. Bones are classified
according to their shape: long, short, flat, irregular and sesamoid bone.
The skeleton system has two main parts: the axial skeleton consist of the bones of
the head, neck and trunk and appendicular skeleton consist of the bones of the limbs,
including those forming the pectoral and pelvic girdles.Thoracic skeleton (bony thorax)
dibentuk oleh 12 pasang costae (ribs) dan costal cartilages, 12 thoracic vetebrae dan
intervertbral disc dan sternum.
SCENARIO
Case 1
A 65-year-old man and a14-year-old boy were involveed in severe automobile
accident. In both patients the thorax had been badly crushed. X-ray examination revealed
that the man had five fractured ribs but the boy had no fractures.
Learning task
1. What is the most likely explanation for this difference in medical findings?
2. Explain why the last two ribs are prone to fracture?
3. Describe the type of the ribs and how they joint with other bones.
Case 2
A medical student offered to move a grand piano for his landlady. He just finished his
final examinations in Anatomy and was in poor physical shape. He strugled with the antique
monstrosity and suddenly experienced an acute pain in the back, which extended down the
back and outer side of his left leg. On examination in the emergency department, he was
found to have a slight scoliosis with the convexity on the right side. The deep muscles of the
back in the left lumbar region felt firmly than normal. No evidence of muscle weakness was
present, but the left ankle jerk was deminished. The symptoms and signs of the patient
strongly suggested a diagnosis of prolapsed intervertebral disc.
Learing task
1. Why the doctor concluded that the patient suffered from prolapsed intervertebral
disc?
2. What is the normal position of lumbar vetebrae in erect position?
Case 3
A 45-year-old man was seen in the emergency department after beeing knock down
in a street brawl. He had received a blow on the right head with an empty bootle. On
examination the patient was conscious with swelling on his upper right head and right face.
The head skin is intact and he could not move his lower jaw.
Learning task
1. What layer of SCALP the hematoma occupied?
2. If the lateral side of cranium was injured, what muscles and bones are suffered?
3. What probably occured to him so he could not move his lower jaw?
4. What structures involve in temporomandibular joint movement?
Self assessment
1. Describe the functions of bones and muscles
2. Describe the name of skeletal muscles according to their location, attachment, form,
direction of the fibers and its function
3. Discribe the parts of bones and muscles
4. Describe some clinical aspects of musculoskeletal system and its implications
5. Describe the name of bones that construct the axial skeleton
6. Identify SCALP, facial muscles and mastication muscles
7. Compare the new born-baby and adult cranium
Day 2nd
MODULE
2
CONGENITAL BONE DISORDER
Prof. Dr. dr, I Ketut Siki Kawiyana,SpB. SpOT(K)
AIMS:
Establish tentative diagnosis, provide initial management and/or refer patient with congenital
anomaly of musculoscletal system.
LEARNING OUTCOME:
Establish tentative diagnosis, provide initial management and/or refer patient with
o CTEV
o CDH
CURRICULLUM CONTENTS:
1. Principle management of congenital anomaly of musculoscletal system.
2. Establish tentative diagnosis, provide initial management and/or refer patient with
a. CTEV
b. CDH
ABSTRACTS
SCENARIO
Case I
A lecturer showed one of his medical students, a 4 months old female patient with
abnormalities in her left lower limb, shortening in her thigh, adducted and difference in skin
fold between her right and left thighs. Lecturers said this patient might be having DDH
(Developmental Dysplasia of the Hip)
1. Where is the abnormality occured and why is it called DDH?
2. What are the incidence, etiology and pathogenesis of DDH?
3. How do you diagnosed and treat DDH patient based on age of the patient?
Case II
A normal male baby was born in a maternity clinic, with normal body weight, cried
spontaneous after examined by midwife. She found both of the baby’s legs bowed inwards.
She has a daughter studying in medical faculty. She asked her daughter about the
abnormalities in this baby and how to treat this baby appropriately.
1. What are the congenital abnormalities found in lower limb?
Case III
A newborn baby found born with both of his legs bowed inwards
1. What are the congenital abnormalities found in this baby?
2. What are the radiologic examinations needed to be done for this patient?
3. What are the radiologic imaging are expected in this patient?
Learning Task:
1. Definition of congenital abnormalities in musculoskeletal system
2. Congenital abnormalities that is common found
3. Signs and diagnostic criteria
4. Management procedures
5. Consultation patient with congenital abnormalities
Self Assessment:
1. What is the meaning of congenital abnormalities?
2. When do you refer a newborn baby with congenital abnormalities?
Day 3rd
MODULE
3
BONE DEVELOPMENT AND ITS MICROSCOPIS STRUCTURE
Dr.dr. Ni Made Linawati, M.Si
Prof. Dr. dr. I Putu Gede Adiatmika, M.Kes
MICROSCOPICS OF BONE
AIMS :
1. Describe normal bones as structure and bone as an organ and apply its concepts
and principles in the approach of patient with healing/injury
2. Describe several factors that affect to regulation of calcium and bone remodeling in
the patient with healing/injury
LEARNING OUTCOME:
1. Comprehend the concept of microscopic bone structure and it’s development
2. Apply the concept to clinical case such as osteoporosis, bone fracture
3. Comprehend the physiology of calcium and its regulation within the body.
4. Apply the concept calcium balance to bone fracture / injury
CURRICULUM CONTENTS:
a. Bone :
Intra membraneous ossification
Endochondral Ossification
Compact / lamellar bone
Woven bone
b. Cartilage :
Hyaline cartilage
Elastic cartilage
Fibrocartilage
c. Bone development
d. Bone deposition, bone absorption
ABSTRACTS
matrix cavities called lacunae. There are three forms of cartilage: hyaline cartilage, elastic
cartilage and fibrocartilage.
Bone is specialized connective tissue composed of intercellular calcified material, the bone
matrix, and 3 cell types: osteocytes, osteoblasts and osteoclast. Microscopic
examination of bone shows 2 varieties: primary, immature or woven and secondary,
mature or lamellar bone. Bone can be formed in 2 ways: by direct mineralization of matrix
secreted by osteoblast (intramembranous ossification) or by deposition of matrix on a
pre-existing cartilage matrix (endochondral ossification).
Joint regions were bones that are capped and surrounded by connective tissue that hold the
bones together and determine the type and degree of movement between them. Joint may
be classified as synostosis, synchondrosis and syndesmosis. In synostosis, bone is united
by bone tissue and no movement takes place. In children and young adult, are united by
dense connective tissue. Synchondroses are articulations in which the bone is joined by
hyaline cartilage. Diarthroses are joints that generally unite long bones and have great
mobility. In this joint, ligament and a capsule of connective tissue maintain the contact at the
end of bone. The articular surfaces of a diarthrosis are covered by hyaline cartilage that is
devoid of perichondrium. The capsule of dioarthroses varies in structure according to the
joint. Generally, this capsule is composed of 2 layers, the external fibrous layer and the
internal synovial layer. The synovial layer is formed by two types of cells. One resembles
fibroblast and the other has the aspect and behavior of macrophages. The fibrous layer is
made of dense connective tissue.
SCENARIO
Female 13 years old, had first menstrual cycle. She complained about her height
that couldn’t increase again.
Learning Task :
1. Describe the histogenesis of cartilage
2. Describe the normal structure and function of hyaline, elastic and fibrocartilage
3. Describe the microscopic structure of osteoprogenitor cells, osteoblast, osteocyte,
osteoclast and bone matrix
4. Describe the organization of immature and lamellar bones
5. Describe the histogenesis of bones, included :
a. Intramembraneous and endochondral ossification
b. Growth in length of long bones
c. Growth in diameter of long bones
d. Surface modeling of bones
6. Describe the histology structure of articular surface of joint.
Self Assesment
1. Chondrogenesis (cartilage growth) takes place by two mechanisms: (1)……….. and
(2)………………..
2. The two major cell components of bone are the …………….. and…………………
3. Explain the process of bone growth and remodeling
SCENARIO
A woman, 45 years old, come to hospital for thyroid and parathyroid surgery. For the
preparation, the patient must do some assessment and therapy a better result after surgery.
Learning Task :
1. Identify any assessment that must done by this patient.
2. Explain what the effect of parathyroid surgery to the other organ and calcium
balance.
Self Assesment
1. What is the effect of parathyroid surgery ?
2. What should be given to patient to avoid hypocalcemia ?
3. What is the mechanism of organ to anticipate loss of parathyroid organ after the
surgery ?
Reference:
1. Junquera LC. 2003. Cartilage and Bone in Basic Histology tenth edition. P. 135-156
2. Textbook of Medical Physiology, 10th ed, A.C. Guyton, Hall, Philadelphia, WB
Saunders Co, 2000, pp. 52 – 95
Day 4th
MODULE
4
BONE AND METABOLISM DISORDERS
Prof. Dr. dr. I Ketut Siki Kawiyana, SpB. SpOT (K)
AIMS:
Establish tentative diagnosis, provide initial management and/or refer patient with
methabolic disorders.
LEARNING OUTCOMES:
Establish tentative diagnosis, provide initial management and/or refer patient with :
osteoporosis, rickets osteomalacea.
CURRICULUM CONTENTS:
1. Osteoporosis
2. Rickets
3. Osteomalacea.
ABSTRACTS
OSTEOPOROSIS
Osteoporosis is a disease that thins and weakens the bones to the point that they
become fragile and break easily. Women or men with osteoporosis most often break bones
in the hip, spine, and wrist, but any bone can be affected.
Osteoporosis is often called “silent” because bone loss occurs without symptoms. People
may not know that they have osteoporosis until a sudden strain, bump, or fall causes a bone
to break. Bone is living tissue. Throughout our live, the body breaks down old bone and
replaces it with new bone (remodeling). But as people age, more bone is broken down than
is replaced. The bone will become thin and porous (osteoporosis).
Risk Factor:
- Gender.
- Age.
- Ethnicity.
- Family history.
- Life style: diet, Calcium, vit D,
- Physical activity.
- Smoking
- Low body weight
- Medication
The best screening test is dual energy X-ray absorptiometry (DEXA). This procedure
is quick, simple and gives accurate results. It measures the density of bone in spine, hip and
wrist.
Treatment & drugs:
Prescription drugs can help slow bone loss and may even increase bone density
over time. It was including: hormonal therapy, bisphosphonates, and calcitonin.
Prevention:
Getting adequate calcium and vitamine D is an important factor in reducing risk of
osteoporosis. Other tips for prevention: exercise, add soy to diet, don’t smoke, avoid
excessive alcohol, and limit caffeine.
SCENARIO
A 60 year old woman came to the orthopaedic clinic due to pain on her back since a
year ago and already got treatment from general practitioner. She said that her back start to
bent since 3 months and severe pain since yesterday because of fall down in sit position.
She had gynecological operation when she was 40 year old
1. Please make imaginative anamnesis in this patient to lead to osteoporosis
diagnosis.
2. What is the Differential Diagnosis? Please explain other examinations which can
distinguish the DD.
3. What is the definition of osteoporosis?
4. What is the pathogenesis?
5. Is osteoporosis happened in female only?
6. How to prevent it?
7. In which bone, can fracture happened if this patient fell down?
Learning Task:
1. Osteoclast and osteoblast function
2. Bone remodeling process
3. Factors that affect bone remodeling
Self Assessment:
1. What is the osteoporosis classification?
2. Why in colles fracture often associate with pathological fracture?
Day 5th
MODULE
5
PATHOLOGY ANATOMY OF MUSCULOSKELETAL DS
Dr. dr. I G.A.Sri Mahendra Dewi, SpPA
AIM:
Describe the etiopathogenesis and morphologic features of musculoskeletal
diseases and apply it concept for approach of musculoskeletal problems and its therapy.
LEARNING OUTCOMES :
1. Bone
1.1 describe the effect (etiopathogenesis and morphologic features) of stress/ injury/
disease to bone.
2. Joint
2.1 describe the effect (etiopathogenesis and morphologic features) of stress/ injury/
disease to joint.
3. Muscle
3.1 describe the morphologic features of skeletal muscle tumors.
3.2 describe the morphologic features of smooth muscle tumors.
4. Soft tissue
4.1 describe the morphologic features of adipose tissue tumors.
4.2 describe the morphologic features of fibrous tissue tumors.
CURRICULUM CONTENTS
1. Bone
1.1 Congenital and Hereditary Diseases of Bone : Achondroplasia, Osteogenesis
Imperfecta
1.2 Osteoporosis and Acquired Metabolic Diseases (Rickets and Osteomalacia)
1.3 Osteomyelitis and Spondilitis
1.4 Bone Tumors : primary and secondary bone tumors, osteosarcoma, Ewing sarcoma,
fibrous dysplasia
ABSTRACT
1. BONE
Achondroplasia is an inherited disorder characterized by impaired maturationof
cartilage in the developing growth plate. The most conspicuous changes are marked,
disproportionate shortening of the proximal extremities, bowing of the legs, and a lordotic
(sway-backed) posture. The cartilaginous growth plates contain hypoplastic or disorganized
aggregates of chondrocytes instead of the long, orderly columns normally seen at this site.
2. JOINT
Osteoarthritis also termed degenerative joint disease. In most cases it arises without
obvious predisposing factors (primary). Morphologically, the earliest structural changes are
enlargement & disorganization of the chondrocytes in the superficial part of the articular
cartilage. These accompanied by fibrillation (splitting) at the articular surface. Portions of the
articular cartilage are eventually completely eroded, cyst may form in the underlying bone.
Additional bone proliferation occurs at the margins of the joints to produce bony
excrescences, termed osteophytes. Non specific inflammation can develops.
3. MUSCLE
Rhabdomyosarcoma is predominantly a neoplasm of infancy, childhood and
adolescence, with the peak incidence in the first decade of life. Microscopically there are
three variants : embryonal, alveolar and pleomorphic.
Leiomyoma is common benign smooth muscle tumors, encountered most frequently in
the uterus, composed of hyperplasia of smooth muscle cells arrayed in whorled-like without
anaplastic appearance.
Leiomyosarcoma is malignant smooth muscle tumors, occur most often in the uterus
and gastrointestinal tracts, composed of hyperplasia of smooth muscle cells with anaplastic
appearance, with infiltrative growth.
4. SOFT TISSUE
Soft tissue tumors are generally classified on the basis of tissue type that they
recapitulate, including tumors of adipose tissue (lipoma and liposarcoma), tumors of fibrous
tissue (fibroma and fibrosarcoma). Lipoma is benign tumor, soft, yellow mass, composed of
mature adipose tissue. Liposarcoma is malignant neoplasm, a number of different histologic
subtypes are recognized, including well-differentiated, myxoid, round cell, pleomorphic and
dedifferentiated liposarcoma. Fibrosarcoma is malignant neoplasm, composed of interlacing
fascicles of fibroblast, sometimes arranged in a ‘herringbone’ pattern.
SCENARIO
A 72 years old woman came to a general hospital with chief complain pain and
swelling in proximal region of her right lower extremity, after she fall in the bathroom.
Radiograph examination showed fracture of femoral neck and decreased of bone density.
Learning task :
1.1 What is the possible diagnosis of this patient ?
1.2 What are the role of hormonal factors in this case ?
1.3 Describe the morphologic features of the femoral bone of this patient.
A 22 years old man came to a doctor with chief complain swelling and pain in his
knee, enlarge fast since a week ago. Radiograph examination showed lesion in
metaphyseal region of distal femur, destroy the cortex, elevate periosteum and extend into
the soft tissue. Biopsy was done in this patient.
Learning task :
2.1.What is the possible diagnosis of this patient ?
2.2 Describe the morphologic features of the biopsy specimen.
A 35 years old man came to a general hospital with chief complain subcutaneous
masses, enlarge slowly since about 3 years ago, without pain. Biopsy was done in this
patient. The result of histopathological examination was lipoma.
Learning task :
3.1 Describe the morphologic features (macroscopic and microscopic) of the biopsy
specimen from this patient.
3.2 Mention some histopatological variant of lipoma.
Self Assessment
1. BONE
1.1 Disorders of the skeletal system can occur in many nutritional and endocrine
disorders. Describe the morphologic appearance of osteoporosis.
1.2 The most common etiologic agents of osteomyelitis are pyogenic bacteria and
Mycobacterium tuberculosis. Describe the macroscopic and microscopic appearance
of acute & chronic osteomyelitis, and tuberculous osteomyelitis.
1.3 Diagnosis of bone tumors require integration of the clinical history, radiologic,
macroscopic and microscopic appearance of the tumor. Describe the macroscopic
and microscopic appearance of the :
1.4 Bone-forming tumor (osteoma, osteoid osteoma and osteoblastoma, and
osteosarcoma).
1.5 Cartilaginous tumors (osteochondroma, chondroma and chondrosarcoma).
2. JOINT
2.1 The most common disorder of the joints is degenerative joint disease. Describe
some sequences in morphologic appearance of that disorder.
2.2 Gout arthritis is caused by the tissue accumulation of excessive amounts of uric
acid. There are four major morphologic manifestations of gout arthritis. Describe the
four manifestation above.
2.3 The most common form of infectious arthritis are caused by bacteria. Describe the
macroscopic and microscopic appearance of acute suppurative arthritis.
3. MUSCLE
3.1 Describe the macroscopic and microscopic appearance of rhabdomyosarcoma
3.2 Describe the macroscopic and microscopic appearance of leiomyoma and
leiomyosarcoma
4. SOFT TISSUE
Describe the macroscopic and microscopic appearance of soft tissue tumor :
- adipose tissue : lipoma and liposarcoma
- fibrous tissue : fibrosarcoma
Learning Resources :
Robbins Basic Pathology, 7 th ed, Kumar V, Cotran RS, Robbins SL. WB Saunders,
Philadelphia, 2003, pp 755-787.
Day 6th
MODULE
6
ORTHOPAEDIC PROBLEM AND ITS MANAGEMENT
Dr. dr. Elysanti, SpRad
Prof. Dr. dr. Putu Astawa, SpOT(K), M.Kes
AIMS:
Describe the clinical management of musculoskeletal disorders (Dx, RO”, Lab. Th.
medical, operative and rehabilitation)
LEARNING OUTCOMES:
CURRCIULUM CONTENS:
1. history taking, (fundamental four and secret seven) of MSD’s
2. physical examination of MSD’s
3. investigation routine and specific of MSD’s
4. modality of treatment of MSD’s
SCENARIO
Ten years old boy came to orthopaedic clinic with main complain swollen in the right
knee due to trauma 1 week ago. The swollen has already developed before trauma and
pain has already developed several months before. Patient’s bodyweight felt decrease 1
month ago. No fever.
Learning Task:
1. From the story above, what need to be asking to the patient? (Remember the secret
seven and fundamental four).
2. Make the physical examination of this patient with imagination in correlation with the
story above.
3. What is the differential diagnosis of this patient?
4. Please explain the pathogenesis from each of the differential diagnosis that has
been mentioned above!
5. What is the planning diagnosis that you suggest?
6. If you want to make an X-ray, how to make a good photo? (Remember the rule of
two).
7. How to read an X-ray photo of bone in generally?
8. If you doubt in make a diagnosis then need a biopsy and pathological examination.
How is the general pathological appearance of chronic infection, TBC and bone
malignancy?
Self Assessment:
1. How to do a good anamnesa in musculoskeletal cases
2. How to do a good physical examination in musculoskeletal cases
3. What is the laboratory findings that need to be checked in musculoskeletal cases
4. How to do radiologic imaging and reading in musculoskeletal cases
5. What is the etiology of musculoskeletal cases in general
LEARNING OBJECTIVE
Learning Task
Self Assessment
1. How to know the fracture in X – Ray
2. How to know the osteomyelitis
3. How to know the osteosarcoma
Day 7th
MODULE
7
THE APPENDICULAR SKELETON
Prof. Dr. dr. Mangku Karmaya, M.Repro
AIMS:
Establish the appendicular skeleton for human movement
LEARNING OUTCOMES:
Comprehend the macroscopic aspect of appedicular skeleton
CURRICULUM CONTENTS:
1. Upper
2. Lower limb
ABSTRACTS
Both appendicular skeletons that build upper and lower limb have the similar patern.
They attach at axial skeleton through girdle. Humeral joint is analog to hip joint, humery
analog to femur, elbow joint to knee, radius ulna to tibia fibula, wrist to ankle and hand to
foot. Due to work load of both appendicular skeletons, joint and lower limb muscles are
stronger than upper limb. The type of joint promotes for upper limb for more free movement,
pronation supination and occur inversion eversion on lower limb. The phalanges of hand
can do apposition movement compare to foot is not possible. All of the appedicular skeleton
were covered by group muscles, and their type are similar.
UPPER LIMB
SCENARIO
Case 1
A15-year-old girl, while demonstrating to her friends her proficiency at standing on
her hands, suddenly went off balance and put all her body weight on her left outstretched
hand. A distinctive cracking noise was heard, and he felt a suddent pain in her left shoulder
region. On examination in the emergency department, the smooth contour of her left
shoulder was absent. The clavicle was obviously fractured, and the edge of the bony
fragments could be palpated.
Learning task
1. Which part of clavicle that the fracture commonly occurs. Why?
2. What is the position of lateral and medial fragments according to muscles traction?
3. Describe all bones that joint the clavicle.
4. What is the function of clavicle?
Case 2
A 63-year-old man fell down a flight of stairs and sustained a fracture of the lower
end of the left radius. On examination the distal end of the radius was displaced posteriorly.
This patient has sustained a Colles’ fracture.
Learning task
1. Why the distal end of the radius was displaced posteriorly?
2. Describe all bones that joint the tradius
3. Describe all muscles attached to the radius
LOWER LIMB
Case 1
After recovery from long hospitalization, a 65-year-old woman try to walk alone. But
suddenly she fell down. The doctor noted that the woman had a spontaneous fracture of the
neck of the femur . The neck fractures are common and are of two types, subcapital and
trochanteric. Subcapital femoral neck fractures are particularly common in women after
menopause.
Learning task
1. Why the fractures have gender predisposition?
2. In the neck fractures the leg become shortened and pointed laterally. Why? (Think
about the muscles pull action).
3. Describe all mucles attached to the neck and shaft of the femur
Case 2
A motocyclist try his new motorcycle in town mainroad in high speed. But he did not
know the truck in front of him suddenly turn to the right. The accident could not be avoided.
After striking hard the truck the man was thrown 10 meters and landed first on his right leg.
On examination in the emergency department the doctor noted fractures of the right tibia
with minimal displacement.
Learning task
1. Why the displacement was minimal?
2. Why the fracture of the shaft of the tibia are more frequent compare to fibula?
3. What muscles are attached to tibia?
Self assessment
1. Compare the upper and lower limb
2. Identify the important parts of upper and lower limb bones
3. Identify the muscles in the regions of shoulder/buttock, fore arm/femur, lower
arm/leg, hand/pedis
Day 8th
MODULE
8
BONE FRACTURE
dr. Wien Aryana, SpOT
AIMS:
Establish tentative diagnosis, provide initial management and/or refer patient with:
Fracture and dislocation in child and adult.
LEARNING OUTCOMES:
Establish tentative diagnosis, provide initial management and/or refer patient with:
Fracture and dislocation in child and adult.
CURRICULUM CONTENTS:
1. Bone healing
2. Diagnosis, provide initial management and/or refer patient with: Fracture and
dislocation in child and adult.
ABSTRACTS
SCENARIO
Male 30 years old, came to our hospital with painful, swollen on he left thigh and
difficulty to move his leg after traffic accident. He was motor cyclist and hit by a car. On
physical examination: shortening of his left lower leg and false movement found.
1. What symptom and sign you find?
2. Which one is the probably symptom and sign for fracture?
3. Which one is the significant (full blown) symptom and sign for fracture?
Learning Task
1. How fractures happen?
2. Types of fracture
3. How fractures are displaced?
4. Fracture healing
Self Assessment
1. Describe about normal healing of fracture
2. Describe about abnormal healing of fracture
LEARNING OUTCOME
Establish tentative diagnosis, provide initial management and/or refer patient with:
Fracture and dislocation in child and adult.
o Fracture in adult
SCENARIO
Male 25 years old, came to our hospital with painfull on he left thigh and difficulty to
move his leg after traffic accident. He was motor cyclist and hit by a car.
On physical examination: shortening of his left lower leg and false movement found.
1. What is your assessment for this patient?
2. How to manage the patient?
Learning Task
1. The special features of fractures and dislocation in adult and children
2. The general principles of fracture treatment
3. How to diagnosis of fracture and associated injuries
Self Assessment
1. Describe the special features of fractures and dislocation in adult
2. Explain the general principles of fracture treatment
3. How to diagnosis of fracture and associated injuries
4. Describe 3 degree of joint histability
LEARNING OBJECTIVE
Establish tentative diagnosis, provide initial management and/or refer patient with:
Fracture and dislocation in child and adult.
o Fracture in children
SCENARIO
Male, 3 years old, came to emergency unit with painfull on the right elbow and
difficulty to movement his elbow after traffic accident. On physical examination; swelling of
right elbow.
1. What is your assessment for this patient?
2. How to manage the patient?
Learning Task
1. The specific methods of treatment of closed fracture
Self Assessment
1. Describe the special features of fractures and dislocation in children
2. Explain the specific methods of treatment of closed fracture
3. Describe about the complication of fractures
4. Describe about the complication of fracture treatment
Day 9th
MODULE
9
BONE JOINT, TENDONS AND LIGAMENTS
Prof. Dr.dr. Mangku Karmaya, M.Repro
AIMS:
Describe normal structure and function of Joints and articular cartilage and.
LEARNING OUTCOMES:
Apply its concepts and principles in the approach of patient with common arthritis
and related inflammation/ infection
CURRICULUM CONTENTS:
1. cartilage of joint
2. sinovium and sinovial fluid
3. function of Joint
ABSTRACTS
A joint is an articulation, the place of union or junction between two or more rigid
components (bone, cartilages, or even parts of the same bone). Joints show variety of form
and function. Some joints have no movement; others allow only slight movement, and some
are freely movable.
There are three types of joint according to the manner of material by which the
articulating bones are united: (1) fibrous joints are united by fibrous tissue. This type are
found as syndesmosis where a sheet of fibrous tissue, either a ligament or fibrous
membrane, interosseous membrane in the forearm (between radius and ulna) and
gomphosis or dentoalveolar syndesmosis between the root of the tooth and the alveolar
process. (2) cartilaginous joints are united by cartilage or fibrocartilage and (3) synovial
joints, the most common type of joint, that the articulating surfaces are covered with
cartilage and united by a fibrous capsule.
Distinguishing features of a synovial joint are, a joint cavity, articular cartilage that
cover the bone end, and articular or joint capsule (fibrous capsule lined with synovial
membrane) that enclose articulating surfaces and joint cavity. There are several types of
synovial joint: (1) hinge joint (uniaxial: permit flexion and extension only eg., elbow joint), (2)
pivot joint (uniaxial: allow rotation, a round process of bone fits into a bony ligamentous
socket e.g., atlantooccipital joint between atlas /C1 and axis/C2), (3) saddle joint (biaxial:
are shape like a saddle; i.e., they are concave and convex where bones articulate); (4)
condyloid joints (biaxial: permit flexion and extension, abduction and adduction, and
circumduction; eg., metacarpophalangeal joints or digits); (5) plane joints permit gliding or
sliding movement (e.g., acromioclavicular joint) and (6) ball and socket joints (multiaxial:
permit movement in several axes: flexion-extension, abductuction-adduction, medial and
lateral rotation and circumduction, where a rounded head fits into a concavity)
SCENARIO :
Case 1
A 60 year-old-woman fell down the stairs and was admitted to the emergency
department with severe right shoulder pain. On examination, the patient was sitting up with
her right arm by her side and her right elbow joint supported by the left hand. Inspection of
the right shoulder showed loss of the normal rounded curvature and evidence of slight
swelling below the right clavicle. Any atempt at active or passive movement of the shoulder
was stop by severe pain in the shoulder. A diagnosis of dislocation of he right shoulder joint
was made.
Learning task
1. Why the shoulder joint prone to dislocation?
2. Why the downward dislocation more frequent?
3. Describe the shoulder joint, its movement and the muscles involved.
Case 2
A father seeing his 3-year-old son playing in the garden, ran up and pick him up by
both hands and swung him around in a circle. The child’s enjoyment suddenly urned to
tearsand he said left elbow hurt. On examination, the child held his left elbow joint
hemiflexed and his forearm pronated.
Learning task
1. What was really happen to the child’s elbow?
2. Why the elbow position hemiflexed and the fore arm pronated?
3. Describe the elbow joint (the bone, type, capsule, ligaments, synovial membrane).
Case 3
A medical student, while playing football, collided with another player and fell to the
ground. As he fell the right knee, which was taking the weight of his body, was partially
flexed, the femur rotatede medially, and the leg abducted on the thigh. A sudden pain was
felt in the right knee joint, and he was unable to extend it. The student was diagnosed as
having a torn medial meniscus of the kenee joint.
Learning task
1. What is meniscus? What is discus (disc)? What are their differences?
2. What structures involved in forming the knee joint?
3. What kind of movement in the knee joint and what muscles involved in the
movement?
4. Compare the knee joint and elbow joint.
Self assessment
1. Describe the classification of joints and its structures
2. Describe the six major types of synovial joints and give examples for each type and
their possible movements
3. Identify the parts of synovial joint
4. Describe the joint of vertebral column
5. Compare the joints of upper and lower limb
AIMS:
Describe normal structure and function of Tendons and ligaments.
LEARNING OUTCOMES:
Apply its concepts and principles in the approach of patient with musculoskeletal
disorders such as tendinitis
CURRICULUM CONTENTS:
1. Tendon
2. Ligament
ABSTRACTS OF LECTURES
Structure and Function of Ligaments and Tendons
Ligaments and tendons are soft collagenous tissues. Ligaments connect bone to
bone and tendons connect muscles to bone. Ligaments and tendons play a significant role
in musculoskeletal biomechanics. They represent an important area of orthopaedic
treatment for which many challenges for repair remain. A good deal of these challenges has
to do with restoring the normal mechanical function of these tissues. Again, as with all
biological tissues, ligaments and tendons have a hierarchical structure that affects their
mechanical behavior. In addition, ligaments and tendons can adapt to changes in their
mechanical environment due to injury, disease or exercise. Thus, ligaments and tendons
are another example of the structure-function concept and the mechanically mediated
adaptation concept that permeate this biomechanics course. In this section, we will review
aspects of ligament and tendon structure, function and adaptation. These notes follow very
closely Chapter 6 on Structure and Function of Tendons and Ligaments from your text.
We start out again emphasizing those ligaments and tendons have a hierarchical
structure. One schematic of this hierarchical structure is taken from your text, and is a very
famous schematic from Kasterlic:
The largest structure in the above schematic is the tendon (shown) or the ligament itselt.
The ligament or tendon then is split into smaller entities called fascicles. The fascicle
contains the basic fibril of the ligament or tendon, and the fibroblasts, which are the
biological cells that produce the ligament or tendon. There is a structural characteristic at
this level that plays a significant role in the mechanics of ligaments and tendons: the crimp
of the fibril. The crimp is the waviness of the fibril; we will see that this contributes
significantly to the nonlinear stress strain relationship for ligaments and tendons and indeed
for bascially all soft collagenous tissues.
SCENARIO
Case 1
A 54-year-old man was told by his physician to reduce his weight. He was prescribed
a diet and was advised to exercise more. One morning while jogging, he heard a sharp
snap and felt a sudden pain in his right lower calf. Onaxamination in the emergency
department, physician noted that the upper part of the right calf was swollen and a gap was
apparent between the swelling and the heel. A diagnosis of rupture of the right Achilles
tendon was made.
Learning task
1. Why there was a gap apparent between the swelling and the heel?
2. Describe the anatomical and physiological aspects of Achilles tendon.
Case 2
A 27-year-old woma was running across some rough ground when the stumbled and
overinverted her left foot. On examination in the emergency department of the local hospital,
the lateral side of the left ankle was tender and swollen. A small area of hgreat tendernes
was found below and in front of the lateral m,alleolus. X-ray exmination on the ankle joint
was negative. A diagnosis of sprain of the left ankle was made.
Learning task
1. Why overinverted can cause sprain on the lateral side?
2. Describe the ankle joint, the muscles and the movements.
3. What structures as a stabilisator of ankle joint?
Case 3
A worker complained pain on his right elbow after doing painting. There was a
swelling on the joint and become more pain after moving the elbow and grasping. On
examination the doctor suspect a tendon injured.
Learing task
1. What tendon supposed to be injured? Why?
2. Describe the elbow joint, its movements and its muscles.
Self assessment
1. Describe the differences between ligament, tendon, aponeurosis, synovial tendon
sheaths and bursae and their functions
2. Describe the intra and extra articular ligaments
3. Describe some clinical aspects of the ligaments, tendon, aponeurosis, synovial
tendon sheath and bursae.
Day 10th
MODULE
10
BONE AND IMUNOLOGY DISORDERS
(OSTEOARTHRITIS AND GOUT ARTHRITIS)
Prof. Dr. dr. Tjok Raka Putra, Sp.PD
AIMS:
Establish tentative diagnosis, provide initial management and/or refer patient with
imunologis disorder.
LEARNING OUTCOMES:
Establish tentative diagnosis, provide initial management and/or refer patient with
osteoarthritis
CURRICULUM CONTENTS:
1. Osteoarthritis
2. Gout
ABSTRACTS
The new definition Osteoarthritis (OA) is a result from mechanic and biochemistry
phenomenon where imbalance between degradation and synthesis from chondrosit
cartilage and matrix extracellular and subchondral bone. OA is a form of arthritis that
common happened in human. Clinically OA is characterized with joint stiffness, pain and
motion disorder, which in late state can develop deformity and immobilization. Osteophyte in
cartilage can be found in radiographic findings. Estimation 10-30% of OA patients will
become permanent disable; therefore OA is the main cause of chronic dysfunction
worldwide. Treatment of OA until now is still unsatisfied, and the goal treatment is to reduce
pain and disabilities.
SCENARIO
A 57 year old woman government servant, a Balinese pensioner came to hospital
with main complaint swelling of right knee since 2 months ago. She also complains pain
while moving around. She has the relapse during religious occasion in her village. Her
weight is 67kg and height 156cm. At the moment, she is active as a Hindu priest.
1. What are other things that have to be asked in patient with swelling and pain in the
knee?
2. What associate factors those need to be asked?
3. What other risk factors should be asked in this patient?
1. What other physical examination should be find in this patient?
4. What are the diagnosis criteria in this patient?
5. What is the general management in this patient?
6. What is the medication should be given in this patient?
7. How do you educate this patient?
8. When do we refer this patient to expertise? And what expertise?
Learning Task
1. Joint Anatomy
2. Joint disorder in Osteoarthritis patient
3. Pathogenesis of Osteoarthritis
4. Diagnosis criteria in Osteoarthritis
5. Management of Osteoarthritis
Self Assessment:
1. Please state types and etiology of OA
2. Please state pathogenesis of OA
3. What are the pathology found in OA
4. What are the diagnostic criteria in OA
5. What are the complications in OA
LEARNING OBJECTIVE
Establish tentative diagnosis, provide initial management and/or refer patient with:
Gouty arthritis/Pseudo Gout
ABSTRACTS
Gouty arthritis is a disease of uric acid metabolism disorder, characterized by
hyperuricemia and uric acid crystal deposits in joint, predominantly at big toe. Gouty arthritis
is a group of heterogenic disease caused by deposition of uric monosodium crystal in tissue
or supersaturation of uric acid in extracellular fluid. Gouty is a disease caused by uric acid
metabolism, manifested by gouty arthritis, uric acid accumulation in tissue, uric nephropaty,
uric acid stone in kidney. Most of gouty arthritis common in men (90%), with peak of acute
attack in fifth decade of life, in woman it commonly occured after menopause. Management
of gouty arthritis patient should be comprehensive and continuous. Basic principle of the
management is normal uric acid serum regulation.
SCENARIO
A 45 year old Balinese Male, with height 170 cm, weight 65 kg, complaint pain and
swelling in his left big toe since yesterday. Two day ago, he didn´t complaint any thing and
he just played football in renon field. He had the same complaint before but never this worst.
Patient feels dizzy and malaise. He had history of high uric acid level but 3 months ago the
level was 6.5 mg%. He has no take medication.
Learning Task:
1. What should you ask to the patient if the chief complaint is swelling at big toe?
2. What other complaints that you should ask to this patient?
3. What are the risk factors in this patient?
4. What are the physical examination (general and specific) that you should look in
this patient?
5. How to make proper diagnosis in this patient?
6. What is the management in general?
7. What medication should be given to this patient?
8. What other education should be given to this patient?
9. When this patient should be referred to expertise? To what expertise?
Self Assessment:
1. What is hyperuricemia?
2. What is the pathologic manifestation of hyperurecemia?
3. What is the pathogenesis of gouty arthritis?
4. What are the diagnosis criteria of gouty arthritis?
5. What is the gold standard to diagnose gouty arthritis?
6. What are the complications of gouty arthritis?
7. What is the management of gouty arthritis?
8. What medication should be given in acute gouty arthritis?
9. What is the management of intercritical and chronic gouty arthritis?
10. What is the diet in gouty arthritis patient?
Day 11th
MODULE
11
SKELETAL MUSCLES
dr. I.G Kamasan Nym Arijana, M.Si. Med
AIMS:
Describe normal of microscopic structure and function of skeletal muscles.
LEARNING OUTCOMES:
Apply its concepts and principles in the approach of patient with musculoskeletal
disorders such as degenerative disease of muscle (Duchene, Becker)
CURRICULUM CONTENTS:
Microscopic of Skeletal muscle
ABSTRACTS
Histology of Muscle
The muscle cells are mesodermal origin. Their differentiation occurs mainly by
gradual process of lengthening. Muscle tissue is responsible for body movements. Three
types of muscle tissue may be distinguished on the basic of morphologic and fungtional
characteristic. Smooth muscle consists of collections of fusiform cells with light microscope
do not show striation. Striated skeletal muscle is composed of bundles of very long cylindric
multinucleated cells that present cross-striation. Cardiac muscle composed of elongated or
branched cells that run parallel each other and end to end contact are the intercalated disks
and it contraction is voluntary, vigorous and rhythmic.
Analysis of thin section of striated muscle show the present of crossbridges between thin
and thick filament.The head of the myosin, the ATPase head are considered to be directly
involved in transduction chemical into mechanical energy for muscle contraction.
SCENARIO
A 50-year-old man came to the clinic because of the asymetry of his leg: the left leg
being much smaller than the right one. Five months earlier, he had an accident with fracture
of his left leg (tibial bone) and he refused to get an operation. Until now, he has been using
a crutch to support his left leg during walking. The doctor diagnosed him to suffer from
disuse atrophy.
Learning Task:
1. What has happened to the structure of his left skeletal muscle?
2. Describe the microscopic structure of skeletal muscle!
3. Differentiate the skeletal muscle from cardiac and smooth muscles!
4. Describe the structural organization of myofibrils and sarcomere!
Self Assessment:
1. Can you tell me all cell structure that involved in contraction?
2. Please differentiate the three kind of muscle cell?
3. Can you tell me the ultrastructure of actin and myosin?
Day 12th
MODULE
12
MUSCLE CONTRACTION AS MOVEMENT TRIGGER
Prof. Dr.dr. I Putu Gede Adiatmika, M.Kes
AIMS:
Describe bioelectric of excitation and muscle contraction.
LEARNING OUTCOMES:
Apply its concepts and principles in the approach of patient with musculoskeletal
disorders
CURRICULUM CONTENTS:
1. Action potential
2. Muscle contraction
3. Excitation contraction process
ABSTRACT
Human movement is occur under spesific stimulation. Proper stimulus will excite the
nerve to generate an action potential within nerve including axon. Action potential is affected
by sodium and potassium exchange between extracelular and intracellular fluid,
permeability of membrane and membrane threshold. Every stimulation will drive electrolyte
to move pass the membrane and will increase the membrane potential to be action
potential. Action potential stage consist of depolarization and repolarization. All the process
of action potential refers to all-or-nothing principle. Action potential will deliver along axon to
the muscles through neuromuscular junction using neurotransmitter called acetylcholine.
Action potential will spread into the muscle through motor end plate, sarcolemma, t-tubule
and cisternae. The end result of this process is release of calcium ions to the filaments.
Calcium from cisternae will stimulate sliding filamen mechanism where actin and miosin
acttach each other. This process need energy that is provided from anaerobic or aerobic
metabolism and promote contraction. Mechanism of muscle contraction is similar to both
skeletal and smooth muscles. The differences of them are time of contraction, energy
consumed, source of calcium ion and excitation-contraction coupling.
SCENARIO
Case 1
Mr X, 45 years old, brought to emergency unit cause of traffic accident, and the
motor cycle hit his back. On physycal examination, he could not move his lower back was
with the chief complaint of unable to move his lower leg.
Learning Task:
1. Identify the problem of those patients?
2. What did the cause and source of paralyze?
3. Why stimulus from the brain couldn’t move the lower leg?
4. Explain the process of action potential within the axon!
Case 2
On marathon race, one athlete was falling down during the racing and scream that
his left calf was suffer from cramp. He felt very pain on the legs and asked someone to
stretch the legs. The therapist sprayed chlorethyl and massaged the calf. The others gave
the athlete an isotonic liquid, too.
Learning task:
1. Please explain why the athlete suffers from cramp?
2. What is happen of contraction relaxation process within his calf muscles?
3. Identify any factors that affect to contraction process?
4. What is the important process within muscle cell that cause contraction?
5. What the role of electrolit and energy during racing?
6. What type of contraction that able to move the legs during race?
Case 3
One patient came to emergency department with the chief complaint of open wound
on the lower arm and must be stitched. The patient cried and asked for anesthesia from the
doctor. During the stichting, the patient looked happy and asked the doctor what happen to
his wound and why he didn’t feel pain?
Learning Task:
1. Please explain the role of anesthesia in that case?
2. Which one of the neuromuscular components that was blocked?
3. Explain several substances that affect to neuromuscular junction?
Self Assessment:
1. Describe distribution of ions surrounding the cell membrane and concentration of
various ion to tissue electric arrangement, transport ion through Na-K pump and resting
potential membrane.
2. Describe the stage of action potentials on the neuromuscular and its response. Identify
resting, depolarization and repolarization stage.
3. Describe the propagation of action potential on nerve. Explain the principle of “all or
none law” or “All-or-Nothing Principle”.
4. Describe general mechanism of muscle contraction or “sliding filament theory” step by
step from excitation to contraction.
5. Describe the source of energy for muscle contraction.
6. Describe the characteristics of whole muscle contraction such as isotonic – isometric,
slow – fast fibers, motor unit, multiple fiber – frequency summation which can lead
tetanization, muscle fatigue, atrophy – hypertrophy.
7. Describe the transfer impulse process from nerve to muscle
8. Describe the excitation contraction process from nerve to muscles
Day 13th
MODULE
13
MUSCLE AND DEGENERATIVE DISORDERS
dr. Ni Made Susilawati, SpS
AIMS:
Establish tentative diagnosis, provide initial management and/or refer patient with
Degenerative disorders.
LEARNING OUTCOMES:
Establish tentative diagnosis, provide initial management and/or refer patient with
Duchene and Becker Muscular dystrophy
CURRICULUM CONTENTS:
Duchene and Becker Muscular dystrophy
ABSTRACTS OF LECTURES
Dystrophy Muscular Progressive (DMP) is a neuromuscular disease which attacks
the muscle organs. This disease is caused by x-linked recessive. The first symptoms that
occurred is when the patient is 2 year old. The patient shows Gower Sign and waddling gait
sign. The muscle weakness usually can be seen in the proximal muscles.
In the laboratory findings, there will be slight increase in CPK enzyme. The
progressivity of this disease occurs fast, and the patient died at the age of 15 or 40,
depends on the type of DMP.
SCENARIO
The surveillance team AFP health department of Bali Province in Bangli found 2
boys at the age of 6 and 12, suffering from paralisi in 4 extremities which started from lower
extremities to the upper extremities. This started gradually when they were 3 year old. Their
sister doesn’t suffer from this condition.
When the patients lie down and want to get up, they showed as if they were climbing
and can’t stand spontaneously. This complain doesn’t followed by sensibility disorder such
as numbness or tingling sensation. Their calf muscle looks bigger; they walked like duck,
cognitive function impaired. No history of fever or neck injury was found in these patients
before having this complain.
Learning Task:
1. What’s the problem found in the scenario above?
2. What’s the differential diagnosis and what’s the most probable diagnosis?
3. Could you explain the pathogenesis of this disease?
4. Could you explain in detail, the clinical diagnostic of this patient?
5. What do you expect from the physical examination in this patient?
6. What other laboratory would like to perform in this patient?
7. How do you manage this patient?
8. When do you refer this patient?
Self Assessment:
1. What is the genetic characteristic and how it can be passed in their kids?
2. Please explain the clinical signs and symptoms in DMP patient and types of DMP?
3. What other test needed to help the diagnosis?
4. What is the early stage management in this patient and how to suppress the
progressivity of this disease?
5. How is the prognosis in DMP patients based on the type?
Day 14th
MODULE
14
DEGENERATIVE DISORDERS
OF SPINE
dr. K.G. Mulyadi Ridia, SpOT (K) / dr. K. Suyasa, Sp.B, Sp.OT (K)
LEARNING OBJECTIVE
Establish tentative diagnosis, provide initial management and/or refer patient with
Degenerative disorders of spine.
CURICULIM CONTENT
1. Low Back Pain (LBP)
2. Neck Pain
may be aggravated by injury, deformity, and pre – existing disorders of the spine. The
resultant LBP is the most common of symptoms
The interrelated degenerative process in the spine is best considered under the
heading of disc degenerative, segmental instability, segmental hyperextension, segmental
narrowing, and herniation of the disc. The treatment of patients with degeneration disorders
in the spine is base in the following aims:
1. To alleviate pain
2. To help the patient understand the nature of the disorders
3. To provide psychological support
4. To strengthen weak trunk muscles
5. To improve function
6. To rehabilitate the individual patient
The methods of treatment are: Psychological consideration, therapeutic drug, bed rest,
orthopaedic apparatus, appliances, physical therapy, spinal manipulation, chemo
nucleolysis, surgical apparatus, and rehabilitation.
SCENARIO
55 year old male, automobile mechanic, ex weight lifter, complained back pain since
5 years ago, especially after working, and sitting for long time. Patient also felt morning
stiffness of her back. At 25 year old, patient had back pain referred to his buttocks and right
leg.
Learning Task:
1. How do you do complete anamnesis of the patient with back pain and neck pain?
2. How do you do physical examination in back pain patient and neck pain ?
3. What is the predisposing factor in back pain amd meck pain patient?
4. What is the management of back pain and neck painpatient?
5. What is your advice for those patient?
Self Assessment:
1. Please draw the anatomical structure of spine
2. What are the structures in the lumbal area that might cause back pain?
3. What are the structures in the lumbal area that might cause neck pain?
AIMS:
LEARNING OUTCOMES:
CURRICULUM CONTENTS:
MODULE
16
HISTOLOGY OF BONE, CARTILAGE, MUSCLE
Team
AIMS:
MODULE
17
PHYSIOLOGY OF MUSCLE CONTRACTION
MUSCLE STRENGTH CONTRACTION
Team
AIMS:
MATERIAL:
1. Kimograf SET
2. Manset spigmomanometer.
3. Ergograf
4. Metronom
MODULE
18
AIMS:
LEARNING OUTCOMES:
CURRICULUM CONTENTS:
MODULE
19
PHYSICAL DIAGNOSTICS OF MUSCULOSKELETAL DS
Team
AIMS:
LEARNING OUTCOMES:
CURRICULUM CONTENTS:
Day 20th
MODULE
20
MID – TERM TEST
Student will be assessed using pcture of bone and muscle. The picture are provided and the student must
give the name of bones or muscles acoording to the pointer on the picture
Day 21st
MODULE
21
NEOPLASM OF SOFT TISSUE & BONE (BENIGN)
Dr. Eka W, Sp.OT
AIMS:
Establish tentative diagnosis, provide initial management and/or refer patient with
various soft tissues tumors and tumor-like lesion and benign neoplasm
LEARNING OUTCOMES:
Establish tentative diagnosis, provide initial management and/or refer patient with
various soft tissues tumors and tumor-like lesion and benign neoplasm
CURRICULUM CONTENTS:
1. soft tissues tumors and tumor-like lesion and
2. Benign neoplasm
a. Osteochondrome
b. Gct
c. Osteoma
d. Osteoid osteoma
ABSTRACT
Bone tumor or tumor from bone is rare case that only 0.2 % from all tumors. Bone
tumors are benign and malignant. Cancers of bone can be primarily from bone itself, or
secunderly from another site.
Benign neoplasm of bone usually found unpredictable, because no specific symtoms
before it give complication like compression to the surrounding tissues or a fracture.
Conversely bone cancers always give similar signs as another diseases like osteomyelitis
or fracture of bone, and bone cancers always be found with bad condition.
The management of bone tumors particularly for malignant tumors, early diagnosis is
very imfortant for further treatment. The modality of management is defending on the
gradation. To know about the stadium, cooperation between orthopaedi, radiology and
pathology anatomy are necessary.
Vigilance for the bone tumors should be increase because sign of malignant bone
tumor always mistakable with another case. Malignant bone tumor usually (75%) attack
childrents and need radical surgery, extensive, and chemotherapy which uncomfortable,
and that are challenge to be an orthopaedic for treating bone tumors. Because of that to be
general practitioner to impeach bone tumor will increase early diagnosis and good result in
the management.
SCENARIO
Case 1
A boy come with lump at the bone of the right thigh close with knee, and below of the left
knee. His family doesn’t suffering disease like him, but his farent has lump like him.
Learning Task:
1. What the problem with him?
2. What kind of anamnesis which necessary for the patient?
3. What kind of physical examination and pem. Tambahan which necessary for the
patient?
4. If the the lump is benign, can you make the classification of bone tumor by Aegerter?
5. Explain, what the meaning with reactive bone lesion, hamartoma ?
6. What are the clinical feature, radiologic, and histopathology of the benign bone
tumors (Osteoma, Osteochondroma, GCT)
7. How the principely of the management of benign bone tumors?
Case 2
Seventeen year old boy, two weeks ago his right knee hited a table, and now his knee
swollen, redness, warm, and painfull.
Learning Task:
1. What x-ray should be performed?
2. What are yourdifferential diagnoses regarding on location where the patient
complaint?
3. May the patient suffer of malignant bone tumor?
4. What are the radiologically if true malignant bone tumor?
5. What is the prognosis base on the radiology imaging?
6. Can you explain the tumors which have radiology feature patognomonic?
Self Assessment:
1. Learn about the definition of benign and malignant bone tumors
2. Learn the classification of bone tumors
3. Learn about the relation between the location and kind of bone tumors?
4. Learn about the management of benign bone tumors
5. What the classification of bone tumor by Aegerter?
6. Can be the GCT classify into malignant bone tumor?
7. What kind of radiology appearance for the bone tumor generally?
Establish tentative diagnosis, provide initial management and/or refer patient with malign
neoplasm of the bone & soft tissue
LEARNING OUTCOME:
Establish tentative diagnosis, provide initial management and/or refer patient with
malign neoplasm of the bone soft tissue
CURRICULUM CONTENTS:
Malign neoplasm of the bone soft tissue
1. osteosarcoma
2. chondrosarcoma
3. ewing tumor
ABSTRACTS
Bone tumor or tumor from bone is rare case that only 0.2 % from all tumors. Bone
tumors are benign and malignant. Cancers of bone can be primarily from bone itself, or
secunderly from another site (metastasis).
Benign neoplasm of bone usually found unpredictable, because no specific symtoms
before it give complication like compression to the surrounding tissues or a fracture.
Conversely bone cancers always give similar signs as another diseases like osteomyelitis
or fracture of bone, and bone cancers always be found with bad condition.
The management of bone tumors particularly for malignant tumors, early diagnosis is
very imfortant for further treatment. The modality of management is defending on the
gradation. To know about the stadium, cooperation between orthopaedi, radiology and
pathology anatomy are necessary.
Vigilance for the bone tumors should be increase because sign of malignant bone
tumor always mistakable with another case. Malignant bone tumor usually (75%) attack
childrents and need radical surgery, extensive, and chemotherapy which uncomfortable,
and that are challenge to be an orthopaedic for treating bone tumors. Because of that to be
general practitioner to impeach bone tumor will increase early diagnosis and good result in
the management.
SCENARIO
A 10 year old boy complaint about lump around his right knee accompanied with
erythema and pain. The lump and pain were beginning 4 months ago. He looks pale and
skinny. One week ago, he got slipped and fall, the pain is getting worst. After that, this
patient comes to you.
Learning task:
1. Make a complete history of this patient!
2. In physical examination what would you expect to find in this patient? After that,
what other you should do?
3. Please explain the radiograph of bone cancer?
4. Please explain about hysthopathologic of bone cancer ( osteosarcoma,
chondrosarcoma, ewing tumor etc)
5. What is metastase? How is the pathway of bone cancer metastase?
6. What is the principal of bone cancer treatment?
Self assessment:
1. Learn about primary and secondary bone cancer.
2. Learn about management of bone cancer, especially:
a. History taking
b. Radiographic
c. Biopsy
d. Treatment: Surgical and adjuvant
3. What is the commonest bone cancer you can find?
4. What is the differences of primary osteosarcoma and secondary osteosarcoma?
Day 22nd
MODULE
22
BONE INFECTIONS
dr. Wayan Suryanto Dusak, SpOT
AIMS:
Establish tentative diagnosis, provide initial management and/or refer patient with
infection of musculoscletal system
LEARNING OUTCOMES:
Establish tentative diagnosis, provide initial management and/or refer patient with:
Osteomyelitis and Septic arthritis
CURRICULUM CONTENTS:
1. Osteomyelitis and
2. Septic arthritis
ABSTRACTS
SCENARIO
Five years old boy, came to the hospital with pain and swelling on his right hip after
fell down when he played 3 days ago. The child un willingness to use his limb and within 24
hours appears acutely ill:
1. What you assessment for this patient?
2. What is your diagnosis?
3. How to manage the patient?
Learning task:
1. General features of inflammatory process of the musculoskeletal tissue
2. Etiology of AHO and septic arthritis
3. Pathogenesis and clinical features of AHO and SA
4. Treatment AHO and SA
5. Complication of AHO and SA
Self Assessment I:
1. Please explain the definition and sign and symptoms of bone infection
2. Please explain the infection route in bone and cartilage
3. Please explain the osteomyelitis classification
\
Day 23rd
MODULE
23
MUSCULOSKELETAL REHABILITATION
AIMS:
Describe the Rehabilitation of musculoskeletal
LEARNING OUTCOMES:
Describe the Rehabilitation of musculoskeletal after injury degenerative disorders
CURRICULUM CONTENTS:
a. Execerise Therapy
b. Deconditioning
c. Physical modality
d. Prosthesis
ABSTRACTS
Musculoskeletal disorders are the most frequent type of disabilities, and pain is the
most common cause musculoskeletal disability. Musculoskeletal complaint include non
specific symptoms such as pain in the neck, back, and extremities, chronic inflammatory or
degenerative disorders, and a wide range of sports injuries, traffic and occupation accident.
These disorder cause disability, suffering and reduce a person quality of life. Early
mobilization in musculoskeletal disorder is needed for preventing immobilization syndrome.
Management of rehabilitation for musculoskeletal disorders consist of giving some medicine,
physical modality, exercise therapy and sometime need walking aid
SCENARIO
Old men, 40 year, have a traffic accident. In emergency room, is got right thighbone
fracture and left forearm, then planned to do operation. After operation, right thigh muscle
minimizes and stiff in the knee and patient cannot walk.
Learning Task
1. Mention kind of exercise therapy
2. Mention complication of long immobilization!
3. Explain the way of prevention of that complication long immobilization!
4. Mention what physical modalities able to be used!
5. Mention kind of walking aid!
Self Assessment:
What is the role of rehabilitation for the musculoskeletal disorders treatment?
Day 24th
MODULE
24
BONE FORENSIC
dr. Ida Bagus Putu Alit, Sp.F, DFM
AIMS:
LEARNING OUTCOMES:
CURRICULUM CONTENTS:
a. Animal bone
b. Human bone
c. Age of human bone
ABSTRACTS
SCENARIO
Case 1
Skeletal was found by a farmer in the field and reported to police immediately. After
that, police came to secure the skeletal and did an investigation. From the investigation,
police found that the skeletal was 35 year old Indonesian female, Type A Blood, height
149cm. The victim had already given birth twice with history of normal labor. Police asked
for medical examination afterwards. The doctor, who examined, found that the skeletal was
complete human skeletal.
1. What’s the purpose of this investigation?
2. a. To do bone sexing, the most accurate criteria can be seen from pelvic and cranium
bone. Please mention the characteristic of the cranium and pelvic bone based on their
gender.
b. Beside cranium and pelvic bone, gender can also be determined from the other long
bones. What are the differences of the long bones at each gender?
3. Race can be determined based on the characteristic of the skeleton and race indexes
a. Please mention the race characteristics seen on their skeleton
b. Please explain about cephalic indexes and pos-cranial indexes in determining race
4. Bone aging based on skeletal appearance can be evaluated from its ossification center,
teeth eruption, suture closure, symphisis appearance and preauricular surface. Please
mention and explain about bone aging.
5. Besides determining sex and age, pelvic bone can also be used to determine parturitas.
What’s the characteristic of parturitas on the pelvic bone? How’s the process happened?
6. How to determine blood type from the skeleton?
Case 2:
A 40 year old male was hit with a block wood at the right thigh during a fight.
Examination revealed wound and closed fracture femur at middle 1/3th
1. The fracture can be seen with 2 aspects, medical and judicial. What are those terms
means ?
2. Please explain in medicolegal aspect of the fracture.
3. Please define the qualification of the fracture and the reason for the qualification
4. What are the purpose of fracture qualification in the conclusion of visum et repertum
Learning Task:
1. Student know about international protocol analysis
2. Student know about bone and bone change according to age
3. Student know about medicolegal aspect of violence
Self Assessment I:
1. Can we determine bone age?
2. Can we differentiate between human bone and animal bone?
Day 25th
MODULE
25
NSAID AND MUSCLE RELAXANT
dr. I.B. Ngurah, M.Kes
AIMS:
Describe the pharmacologic of NSAID and muscle relaxant
LEARNING OUTCOMES:
1. Describe the classification of NSAID, toxicity and interaction
2. Describe the classification of muscle relaxants, toxicity and interaction
CURRICULUM CONTENTS:
1. Classification the anti-inflammatory drugs, drugs used in Gout
2. Mechanism of actions of the NSAIDs, acetaminophen and drugs used in Gout
3. Pharmacokinetics of the NSAIDs and drugs used in Gout
4. Clinical used of the NSAIDs and drugs used in Gout
5. Toxicities of the NSAIDs and drugs used in Gout
6. Drug drug interactions of the NSAIDs
7. Pharmacologic aspects of Celecoxib, Rofecoxib, Meloxicam, Diclofenac, Diflunizal,
Etodolac, Ibuprofen, Indomethacine, Mefenamic acid, Naproxen, Piroxicam
8. Classification the Disesase-Modifying, Slow-Acting Antirheumatic Drugs (DMARDS,
SAARDS)
ABSTRACT
The treatment of patients with inflammation involves two primary goals : first, the
relief of pain, which is often the presenting symptom and the major continuing complaint of
the patient; and second, the slowing or- in theory- arrest of the tissue-damaging process.
Reduction of inflammation with nonsteroidal antiinflamatory drugs (NSAIDs) often results in
relief of pain for significant periods. Furthermore, most of the nonopioid analgesics (aspirin,
etc) also have anti-inflammatory effects, so they are appropriate for the treatment of both
acute and chronic inflammatory conditions.
The glucocorticoids also have powerful anti-inflammatory effects and when first
introduced were considered to be the ultimate answer to the treatment of inflammatory
arthritis. Unfortunately, the toxicity associated with chronic corticosteroid therapy inhibits
their use except in the control of acute flare ups of joint disease. Therefore, the nonsteroidal
antiinflamatory drugs have assumed a major role in the treatment of arthritis.
Another important group of agents are characterized as slow-acting antirheumatic
drugs (SAARDs) or disesase-modifying antirheumatic drugs (DMARDs). They may slow the
bone damage associated with rheumatoid arthritis and are tought to affect more basic
inflammatory mechanism than do the NSAIDs. Unfortunately, they may also be more toxic
than the nonsteroidal anti-inflammatory agents.
SCENARIO :
A 60-year-old woman complains with intense painful, warmth, redness and great
swollen in the first toe her right foot. Examination of fluid from the inflammed joint revealed
crystals of uric acid. The physician diagnosed the patient as acute attack of Gout.
1. Classify the treatment strategies in Gout arthritis
2. Explain the choice treatment for acute attack of Gout
3. List the toxicities drugs for acute attack of Gout
Learning Task:
1. Classify the anti-inflammatory drugs and drug used in Gout (Trevor, page 307)
2. Describe the mechanism of actions NSAIDs, Acetaminophen and drugs used in
Gout (Trevor, page 307, 311)
3. Explain the pharmacokinetics of theNSAIDs (Trevor, page 308)
4. List the toxicities of the NSAIDs (Trevor, page 309)
5. Describe the clinical used of the NSAIDs (Trevor, page 308)
6. Describe the advantages of the COX2 inhibitor compare with non selective
NSAIDs (Trevor, page 309)
7. List the toxicities of the COX2 selective inhibitor (coxibs), why? (Lecture,
Katzung, page 583)
8. Explain the interaction of the NSAIDs and drugs used in Gout with other drugs
ollowing drugs (Trevor, page 313)
9. Describe the pharmacologic aspects of the Celecoxib, Rofecoxib, Meloxicam,
Diclofenac, Diflunizal, Etodolac, Ibuprofen, Indomethacine, Mefenamic acid,
Naproxen, Piroxicam (Katzung, page 582-587)
10. Classify of the Disease-Modifying, Slow-Acting Antirheumatic Drugs (DMARDS,
SAARDS) (Trevor, page 309)
11. List the toxicities of the glucocorticoid (Katzung, page 594-595)
12. How to use the glucocorticoid in rheumatoid arthritis (Lecture, Katzung, page
594)
Self Assessment:
1. Which of the drugs do not have anti-inflammatory effect
A. Ibuprofen
B. Mefenamic acid
C. Acetaminophen
D. Aspirin
E. Naproxen
2. What’s the toxicity of phenylbutazone ?
A. Vertigo
B. Reye’s syndrome
C. Miosis
D. Aplastic anemia
E. Hypotention
3. Which of the drugs do not have gastric irritation
A. Aspirin
B. Phenylbutazone
C. Diclofenac
D. Celecoxib
E. Mefenamic acid
CURRICULUM CONTENT
- definition
- classification and prototypes
- pharmacokinetics
- pharmacodynamics
- antidote
- toxicity
- interactions
ABSTRACT
Contraction of skeletal muscles is voluntarily controlled by impulses that originate in
the central nervous system (CNS). Impulses from the brain are conducted through the
spinal cord to the somatic motor neurons. Somatic motor neurons eventually connect with
skeletal muscle fibers forming a neuromuscular junction. The neuronal endings of the
somatic motor fibers contain the neurotransmitter acetylcholine (ACH). When ACH is
released into the neuromuscular synapses, it has interaction with cholinergic receptors
known as nicotinic –II (NII) receptors.
Depolarization of the muscle fibers occurs when ACH has interaction with the NII
receptors. Following depolarization, the contractile elements of the muscle fibers (actin and
myosin) produce muscle contraction. Muscle relaxation occurs after ACH is hydrolyzed by
acetylcholinesterase, this terminates the action of ACH.
A variety of neuromuscular blocking agents with varying mechanism of blockade and
pharmacokinetic properties are used to produce muscle relaxation during anesthesia.
Centrally acting muscle relaxants (Baclofen, Carisoprodol, Chordiazepoxide, Chlorphenesin
Carbamate, Diazepam, and Tizanidine) are drugs that relax skeletal muscle by a central
mechanism depress reflex impulse conduction within the spinal cord. Peripherally acting
skeletal muscle relaxants are drugs that inhibit skeletal muscle contraction by interfering
with NII receptors. There are two types of neuromuscular blockers: nondepolarizing (curare,
gallamine and pancuronium) and depolarizing (succinylcholine). Direct acting muscle
relaxants (dantrolene) are drugs that inhibits the skeletal muscle fiber by prevents actin and
myosin contraction.
Standard References
Additional Reading
1. Katzung, B.G.Basic & Clinical Pharmacology, 9th ed, New York, McGraw-
Hill/Lange, 2004 pp.446-462
2. Taylor, P. Agents Acting at Neuromuscular Junction and Autonomic Ganglia in
Goodman & Gilman’s The Pharmacological Basis of Therapeutics. 10th Ed.
Editor: Hardman, J.G., Limbird L.E., and Gilman, A.G. New York, Mc Graw-
Hill/Lange., 2001, pp.193-214
3. Hitner, H., and Nagle, B. Basic Pharmacology, 4th Ed. Singapura, Mc Graw-
Hill/Glencoe. 2002,pp.103-115
SCENARIO :
Mrs. Anita , 45 years old, come to Sanglah Hospital because she had traffic
accident. Doctor in hospital told her that she will have knee surgery. A note on her chart
indicates that she will be given succinylcholine during the operation to relax the muscles in
her leg. Her chart also indicates that she takes digitalis for a heart problem.
Learning task:
1. Assume that you work in a surgical unit where you coordinate patient medications,
identify a potential drug problem in case above and how it might be avoided
2. Explain mechanism action of succinylcholine as peripherally acting skeletal muscle
relaxants
3. Describe at least two ways in which skeletal muscles may be relaxed
4. Describes drugs that reduce the contraction of skeletal muscles affecting posture
and motor function
5. Compare the mechanism of action between depolarizing and non depolarizing
skeletal muscle relaxants
6. List three potential adverse effect associated with muscle relaxants
Self assessment:
1. What are the physiological events that precede skeletal muscle contraction?
2. What adverse effects are produced by the skeletal muscle relaxants as a result of
histamine release?
3. How does dantrolene differ from neuromuscular blockers?
4. What is the mechanism action of centrally acting skeletal muscle relaxants?
5. When are centrally acting skeletal muscle relaxants used?
REFERENCES
1. Essential Clinical Anatomy, 2nd ed, Keith L. Moore and Anne M.R.Agur, Lippincott
William & Willems, Philadhelpia, 2002, pp. 10 - 26
2. Bloom & Fawcett’s Concise Histology, 2nd ed, Fawcett D.N., Jensh, R.P, London,
2002, pp. 79 - 115
3. Textbook of Medical Physiology, 10th ed, A.C. Guyton, Hall, Philadelphia, WB
Saunders Co, 2000, pp. 52 – 95
4. Medical Biochemistry, Baynes J and Dominiczak, London, 1999, pp 497 - 509
5. Katzung & Trevor’s Pharmacology, Examination & Board Review, 6th ed. A.J. Trevor,
B.G. Katzung, Susan B Masters, pp. 322 – 330, 244 – 251.
6. Robbins Basic Pathology, 7th ed, Kumar V, Cotran RS, Robbins SL. WB Saunders,
Philadelphia, 2003, pp. 3 – 31; 756 – 787
7. Textbook of disorder and injuries of the musculoskeletal system, Robert B. Salter
MD Apley’s system Orthopaedics and Fractures. Apley, Solomon, pp 25, 44, 52, 75,
101, 349, 427, 477.
8. Harrison’s, 16th ed. 2005. pp 2029 – 2036
ADDITIONAL TEXTBOOK
9. Review of Medical Physiology, 10th ed, W.F. Ganong, California : LANGE Medical
Publications.
10. Human Physiology – An Integrated Approach. 2nd ed. Silverthorn, 2001New
Jersey : Prentice-Hall Inc.
11. Pocket Companion to Textbook of Medical Physiology, 10th ed, A.C. Guyton,
Hall, Philadelphia, WB Saunders Co, 2000, pp. 52 – 95
STUDENT PROJECT
MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS
2016
_______________________________________
Modul No : ..........
Topics : .....................................................................................
Lecturer : .....................................................................................
Synthesis :
Facilitator
______________
Group : ..........
Class : .....................................................................................
Facilitator : .....................................................................................
Dear Facilitators,
Please observe, appraise and give score to student project of the student in this groups foolowing the
criteria as belows.
10
11
12
Att :
- Complete : content of synthesis related to SKDI and learning task
- Writing : handwriting and easy to read (clear)
- Time : complete and show the task to facilitator according to lecture's
schedule
Score range : 1 - 10
Facilitator
______________