class 4 - Cat`s TCM Notes

Week 4
Chapter 56

Composed of axial (skull, thorax, vertebral
column) and appendicular (upper and lower
extremities) skeletons.

Ligaments: connect bones to bones

Tendons: connect muscles to bones

Connective tissue (bone and cartilage) are
made up of:
◦ Living cells
◦ Non-living intracellular protein fibers
◦ Shapeless ground substance
◦ Intracellular fibers:
 Collagen: inelastic, fibrous, high tensile strength, white
 Elastic fibers: contain elastin-able to repeatedly stretch
then return to normal shape and length. Ligaments
contain a lot of elastic fibers
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
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Firm but flexible connective tissue
Weight bearing capacity exceeded only by
bone
Embryonic skeleton is mostly cartilage then
replaced by bone
Chondrocytes are cartilage cells
Does not contain blood vessels or nerves
65-80% water weight in a gel matrix
◦ Allows diffusion of gases, nutrients and wastes
important - takes a very long time to heal because there
is no blood supply. Gets nutrients through the gel matrix instead.


Elastic cartilage: contains some elastin (ear)
Hyaline cartilage: pure cartilage, white (fetal
skeleton, joint surfaces, costochondral
junctions)
◦ Most surfaces are covered by perichondrium
(fibrous connective tissue)

Fibrocartilage: intermediate between hyaline
cartilage and dense connective tissue
(intervertebral disks)


Connective tissue which is strong but
compressible and light
Intracellular matrix contains
◦ Organic matter (1/3): cells, vessels, nerves
◦ Inorganic matter (2/3): hyroxyapatite-insoluble
structure of calcium salts
◦ May also take up lead and other heavy metals and
the antibiotic tetracycline in newly formed bones
mixture of calcium salts
as bones are forming they are more likely to take up the heavy metals - like tetracycline, like le
kids are more susceptible to lead poisoning.
www.cda-adc.ca/.../issue-2/110/fortin-1.GIF
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Two types of mature bone:

1. Cancellous (spongy): interior of bones
◦ Trabeculae
◦ Filled with red or yellow bone marrow
◦ Compressible

interior of long bones. have more
cancellous material than small bo
or skull.
2. Compact (cortical): outer shell of bones
◦ More rigid
Cortical gives bones and bodies stability.

Classified as
◦
◦
◦
◦
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Long (upper & lower extremities)
Short (ankle, wrist)
Flat (skull, ribcage)
Irregular (vertebrae, jaw)
Red bone marrow contains red blood cells
and blood cell formation. Present in nearly all
marrow in young children, in adults it exists
in vertebrae, ribs, sternum, ilia
Yellow marrow composed of adipose
(pelvis)
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
Diaphysis: shaft
◦ Compact bone with
marrow in the medullary
cavity
growth
our full


Epiphysis: the ends
Metaphysis: part of the
shaft that fans out as it
approaches the
epiphysis, contains bony
trabeculae with cartilage
Long bone anatomy
Metap
to ch
Break
physi
plate

Osteogenic cells
◦ Undifferentiated cells that differentiate into
osteoblasts in normal growth, fractures, injuries

Osteoblasts
◦ Bone building cells, occurs in 2 stages:
◦ 1. Ossification: formation of osteoid (collagen and
proteins)
◦ 2. Calcification: calcium deposited into osteoid
◦ Alkaline phosphatase: the enzyme that is released
by osteoblasts to raise calcium & phosphate
Also a lab test used to
 Level is high in fractures and other conditions
If alkaline phosphatase
adult is a possible ind
or 2) bone cancers. Thi
into the blood to make
formation.

Osteocytes
◦ Maintain the bone matrix
◦ Lie in lakes of fluid called lacuna and connected
with passageways called canaliculi
◦ Arranged in layers called lamellae

Osteoclasts
'Blast - build
'Clast - crush/chew
◦ Function in bone resorption
◦ Produced in bone marrow
◦ Have receptors for PTH, calcitonin & other factors

Periosteum: the outer covering of bones,
except at articulations
Peri = surrou
Bone bruise is a periosteal injury. Can see on Xray -
◦ Outer fibrous layer
◦ Inner layer of osteogenic cells

periosteum.
Will heal but takes a long time.
Endosteum: the membrane that lines the
spaces of spongy bone
◦ Osteogenic cells important for bone remodeling
Endo = inside
A bone tumor
lifting the tibial
periosteum
http://podiatry.files.wordpress.com/2007/03/cbfig_1.jpg
What does the hormone do to t
does it build or tear down bo
what does it do to blood calc
See PG 1361

Parathyroid Hormone
◦ Regulates calcium and phosphate levels in blood
◦ Secreted by parathyroid glands (2 pairs on the thyroid
gland)
...for whatever reason
◦ When calcium levels fall, negative feedback mechanism
causes release of PTH which increases calcium level and
shuts off hormone secretion
◦ Increases serum calcium
◦ Releases calcium from bone (resorption)
◦ Decreases bone formation
◦ Increases intestinal absorption of calcium by activating
Vitamin D
◦ Decreases calcium excretion in kidney
increasin
down bone
increasin
from peei

Calcitonin
Released in response to high
◦ Secreted by parafollicular thyroid cells
◦ Released when serum calcium rises
◦ Inhibits resorption to decrease calcium release from
bone
◦ Inhibits osteoclast activity
◦ Increases renal excretion of calcium and phosphate
going too high.
◦ Probably active in the management of dietary
calcium
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

Vitamin D: obtained from diet (ergocalciferol,
vitamin D2) or from skin production when exposed
to UV light (cholecalciferol, vitamin D3)
Ergocalciferol is converted into cholecalciferol
which is processed in the liver into 25hydroxyvitamin D3 which is transported to the
kidneys and converted into 1, 25 dihydroxyvitamin
D3 (most potent) and 24, 25 dihydroxyvitamin D3
Adequate sunlight exposure should be sufficient
This refers to Vi
1, 25 (OH)2D3 works with PTH to regulate
calcium and phosphate and regulates bone
formation and mineralization
of bone growth/de

Dietary kind
◦
◦
◦
◦
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Increases intestinal absorption of calcium
Increase in osteoclast number and activity
Increased osteoblast differentiation
Deficiencies lead to rickets in children and
osteomalacia in adults (softening of the bones)
24, 25 dihydroxyvitamin D3 increases bone
formation
Sunlight kind
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Connective tissue structures
Tendons: muscle to bone
◦ Aponeuroses-flat sheets of connective tissue as in
abdominal muscles
◦ Some tendons surrounded by tendon sheaths
ropy tendons like in
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Ligaments: bone to bone
Collagen fibers, limited blood supply
Fibrocartilage: the gradual transition of
tendons or ligaments onto bone
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Two classes of joints: synarthroses and
diarthroses
Synarthroses: no joint cavity, very little
movement
Much less mobile.
◦ Synostoses: nonmovable with dense connective
tissue (skull)
◦ Synchondroses: bones connected by hyaline
cartilage, little movement (ribs & sternum)
◦ Syndesmoses: fibrous disk and joined by ligaments,
provide some movement (spine)
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Diarthroses: freely movable joints but still
with a wide range of motion: sacroiliac joints
to shoulders
Surfaces covered by cartilage and held
together by a strong fibrous joint capsule
◦ Outer layer is fibrous
◦ Inner layer is the synovium that secretes fluid that
is normally clear/pale yellow
Joint caps
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Blood supply: vessels enter near the joint
capsule and synovial membrane has a rich
blood supply (so bleeding into the fluid can
occur with injury)
Nerve supply: from the same nerve trunks
that supply the muscles that move the joints
(reason for referred pain)
Pain fibers present in joint capsule and
ligaments, sensitive to stretching and twisting


Bursae: Closed fluidfilled sacs in the
synovial membrane that
prevent friction on
tendons (see Figure 567)
Menisci:
fibrocartilagenous
structures that develop
from an articular disk
that lies between
articular cartilage
surfaces
www.eorthopod.com/images/ContentImages/knee
Chapter 57

MVAs are the #1 killer of adults <45 years

Motorcycle accidents common in young men

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Children: falls, bicycle accidents & sports
injuries
Falls are most common in adults >65 years
◦ 30% in this age group have at least one fall each
year
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

Can be acute injuries to soft tissues (sprains
or strains) or bones (fractures)
Or can be chronic, overuse injuries (stress
fractures or tendinitis)
Can be prevented by training, safety
equipment, warm-up/cool-down, hydration
and proper nutrition
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
Contusion: (a bruise) direct
trauma against a hard object,
overlying skin intact
Hematoma: an area of local
hemorrhage, infection is a
possibility
NOT aspirin!
It's still
bleeding for a
while.
◦ Treat with elevation, cold, possible
aspiration

Laceration: disruption in the
continuity of skin, treat with
closure
◦ Puncture wounds can be
contaminated with tetanus or
anaerobic bacteria
i.e., gas gangrene
http://www.more-mtb.org/galleries/Ouchie2.jpg
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Usually from overloading or forcible twisting
or stretching
Strains: a stretching injury to a muscle or
musculotendinous unit
◦ Most common in lumbar & cervical regions
◦ Can be muscle, ligament, fascial injuries

Sprains: a ligamentous injury
◦ Pain and swelling subside slower than a strain
◦ Ankle is most common, knee, elbow, wrist
◦ Can cause an avulsion fracture
Where ligament hooks onto the bone, might give at the bone where it's hooked on
rather than pop the ligament - breaks off a chunk of bone. See the next slide.
More common in ankle, happens in diabetics. Tender over the bone after injury?
Send for Xray. Tender just on the ligament? Treat with ice, etc.
Avulsion fracture
of calcaneous
The chunk on top used
to be connected to the
heel. probably requires
surgery. Also, must be treated
pretty quickly or the bone
will get necrotic and won't
ever heal.
radpod.org/.../2007/05/calcaneal_avulsion.jpg
Need time to heal tensile strength.

Healing: need to regain tensile strength
◦ Fibroblasts from the inner tendon sheath or from
connective tissue capillaries produce collagen
◦ Full tensile strength restored in 6-8 weeks
to stick things back
Pain might be gone in 2 week

Treatment:
◦ Elevation and cold initially
◦ Compression to reduce swelling & provide support
◦ Gradual return to exercise and rehab
to reduce swelling and bleeding
so not re
strengthen ligs and muscles. also damage pro
ability to learn where you are in space...so
part is and you reinjure more easily.
can be due to pathologic problem - connectives are not funx properly.

Separation of bones with loss of articulation
due to disruption of holding ligaments
◦ Subluxation is a partial dislocation where there is
still partial contact




Congenital dislocations can occur in hip, knee
Traumatic: due to high forces, can be
recurrent
Pathologic: can be due to infection,
rheumatoid arthritis, paralysis
Can be reduced spontaneously, manually or
surgically
Is often non-painful for about 1/2 hour when dislocated because nerve has made a di
as quickly as possible before the muscle wakes up and starts to spasm.
Small pieces of bone or cartilage in a joint
space
Can occur from trauma or worn cartilage
Common in knee, hip, ankle, elbow
Can cause joint to catch and lock
Treated with arthroscopy
and sit within a joint space.
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Anatomy
◦ 3 bones: scapula, clavicle, humerus
◦ 3 joints: acromioclavicular, glenohumeral,
sternoclavicular
◦ Rotator cuff: supraspinatous, infraspinatous, teres
minor and subscapularis

Rotator cuff injuries can be due to acute
injury or with overuse.
◦ Tendinitis, bursitis, impingement, frozen shoulder
overhead painting the ceiling, installing ceiling fans, etc. impingement = abduct and get pain, usually at
about 90 degree angle.
If not treated, end up with frozen shoulder - scarring of shoulder capsule and then cannot raise the arm.
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Injuries can occur to tendons, ligaments,
patella or menisci
Often occur during twisting or compression
Knee injuries always increase the risk for
osteoarthritis later in life
Meniscal tears can be treated conservatively
or with surgery
Patellar subluxation or dislocationconservative treatment first
Chondromalacia- usually on underside of
patella, pain with climbing stairs or sitting
Common site for arthritis anyhow.

i.e., rest,
if a large injury with a big tear and lots of reinjury.


knee cap slides out of its' groov
out of its groove.
front of the knee going up steps or sitting at a desk all day. Underside of the pa
femur and it gets rough underneath.
Patellar Dislocation
www.wheelessonline.com/image9/i1/patd1.jpg
Looking
Normal (smooth)
Chondromalacia
www.emedx.com/emedx/diagnosis_information/


The most common bone lesion
Can be from acute injury, chronic stress or
pathologic
like bone tumor

Characterized by location, type of fracture

Healing occurs in stages:
1. Hematoma formation: first 48-72 hours, initiates
cellular events to start healing
2. Cellular proliferation: periosteum, endosteum and
medullary canal. Osteoblasts multiply
3. Callus formation: cartilage forms first, then
calcifies. Occurs in 3rd and 4th weeks
4. Ossification: final layers of bone are placed, cast
can be removed
5. Remodeling: resorption of the bony callus by
osteoclasts
1. Bloo
and rel
3. Also called a "
4. Cortical
5. Cleanup crew

Treated with immobilization
◦
◦
◦
◦
◦
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Splints
Casts
Traction
External fixation
Internal fixation (plates, wires, screws)
Big gadgets with pins sticking into the bones to stabilize the bone.
Complications
◦ Malunion
◦ Delayed union
◦ Nonunion
Didn't stick back together properly.
Not healing in time expected.
Just doesn't heal.
Like avulsion fractures.

se etc.
ome. Modify
Complications:
◦ Fracture blisters: usually on ankle, elbow, foot, knee and Happen
caused by separation of epidermis and resulting fluid buildup.
Most co
◦ Compartment syndrome: increased pressure in a limited partmen
partmen
space because of inelastic fascia. Neurologic symptoms below =
occur, treatment should occur quickly to avoid ischemia. be able
Treated with fasciotomy.
Skin colo
◦ Reflex sympathetic dystrophy: severe pain and
lack of h
autonomic nervous system dysfunction characterized by sweating
months or
to the pa
temperature changes and hyperhydrosis in the area
◦ Fat embolism: long bone fractures or major trauma, fat
droplets lodge in lung causing respiratory failure, Classically in femu
do but put them a v
cerebral dysfunction, petechial rash
heal itself.
Reflex Sympathetic Dystrophy
www.steadyhealth.com/.../Image/thumb_RSS.gif
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
Acute or chronic bone infection
Hematogenous: most often caused by
Staphylococcus aureus
Hematogenous spread = bact
it likes and latches on. C
users get this because the
blood stream.
◦ Bacteria reaches bone through bloodstream
◦ Usually have chronic infection elsewhere (urinary
tract, skin, IV drug users)
◦ Fever, chills, pain,
◦ X-ray findings may be delayed, bone scan will show
earlier
◦ Treatment based on cultures and requires IV
antibiotics at first, surgery may be required
about 2 weeks.
Draw blood, biopsy, e
to clean out necrotic area. Most often caused by
bigger problem because this is the one that is s


Contiguous Spread:
◦ Infection occurs from an adjacent site like an open wound
(puncture wound, open fracture, diabetic ulcer)
◦ Can occur in any bone
◦ Recurrent, persistent fever and poor healing
◦ Diagnosed through imaging, biopsy
◦ Treated with antibiotics and possible surgery
Chronic osteomyelitis: when acute infection persists
beyond 6-8 weeks
Diabetes
spreads t
fevers ca
Common wit
◦ Dead bone separates from living bone Kind of like an abscess.
◦ May not have fever, chills or abnormal white blood cell
count
◦ IV therapy needed for at least 6 weeks, surgery usually
needed

Tuberculosis can cause bone infection
Can manifest in spine most often. Spin
www.gentili.net/.../large/left_foot_-2.jpg

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Death of a segment of bone
Due to interruption of blood supply
Causes: trauma, fracture, surgery, sickle cell
disease, alcoholism, corticosteroids (higher
risk with longer duration and higher doses)
Treatment ranges from rest and antiinflammatories to joint replacement
Any kind o
Asthma, cystic fibrosis, et

scribed long term. Common i
will get necrotic and hip m
Chapter 58
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Toeing-in and toeing-out
Bowlegs
Knock-knees
Flatfoot
Can start in utero, usually correct during
normal growth

Osteogenesis imperfecta
◦ The most common hereditary bone disease
◦ Usually autosomal dominant

Developmental dysplasia of the hip
◦
◦
◦
◦
◦
Can cause instability, subluxation, dislocation
Checked on newborn exams
Early diagnosis is important
Treated with harnessing, traction, casting
Multifactorial inheritance
Autosomal dominant
Brittle bone disease
dominant.
Check newborn
trochanters a
hip dysplasia
Can get early

Congential clubfoot
◦ Multifactorial inheritance
◦ One or both feet involved
◦ Increased risk with family history and maternal
smoking
◦ Treated with manipulations, casting, surgery
Good pic in book

Legg-Calvé-Perthes Disease
◦
◦
◦
◦

Osteonecrosis of the proximal femoral epiphysis
Ages 2-13, mostly boys
Pain in groin, hip, thigh or knee or painless limp
Treatment ranges from observation to bracing to
surgery
ice. hip bal
esp overweight boys
Osgood-Schlatter Disease
Pretty com
◦ Microfractures where patellar tendon inserts on
tibial tubercle
◦ Pain in front of knee
◦ Worse with running, jumping, biking, stair climbing
◦ Treat with rest, braces, cold, anti-inflammatories
Common - ru
on tibial t
bony spot,
Treat: rest
ice.
Legg-Calvé-Perthes Disease
See how fluffy this
other side.
www.wheelessonline.com/images/bennf2.jpg
Osgood-Schlatter Disease
www.zadeh.co.uk/.../osgood-schlatter_1.jpg

Slipped Capital Femoral Epiphysis
◦ Most common disorder of the hip in adolescents
◦ Femoral epiphysis unites at 14-16 years of age and
slippage can occur before this
◦ Boys affected more than girls
◦ Children often overweight
◦ Knee pain, pain with walking, stiffness
◦ Treated with rest, traction, surgery
More boys, more overweight, often hip pain.
Epiphysis and
Causes malunion or necro
orthopedics.seattlechildrens.org/assets
kinds:




ostural
tructural

Lateral deviation of the spine that can include
rotation or deformity of the vertebrae
More common in girls
Most are minor curves
Postural scoliosis corrects with exercise
Structural scoliosis is fixed and can be
Some pp
Polio was once a big cause of this problem.
Retrains the muscl
◦ Congenital
◦ Neuromuscular
◦ Idiopathic (adolescent is the most common type)
 Right curve most common
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Less than 10 degrees is normal variant, more
than 40 degrees is severe
Can cause shoulder height discrepancy, scapular
differences, clothes fitting differently. Pain
usually only if severe.
Diagnosed through screening ages 10-16, x-ray,
CT, MRI
Early age and larger curves will tend to progress
Conservative treatment with <20 degrees
Bracing for 30-40 degree curves and surgery if
more than 40 degrees
Like PT
www.spine-surgeon.org/Photos/Scoliosis.gif

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
Osteopenia: reduced bone mass
Osteoporosis: loss of bone with deterioration of
bone architecture and increased fragility
Most often due to aging
Lower than normal, not yet osteoporosis.
If you ha
are autom
◦ Endocrine disorders of malignancy also causes



Maximal bone mass occurs at age 30
Increase in rate of bone loss after menopause
with a women’s lifetime risk of fracture 1 in 3
Risks: female, white, small frame, family history,
postmenopausal, smoker, excessive alcohol or
caffeine, low calcium intake, sedentary lifestyle
AGE 30!!!! - So when kids don't
soda their calcium is being boun
kids ar

Imbalance in bone formation and resorption
◦ Decreased osteoblast activity and increased osteoclast
Low blasts, high clasts.
activity

Estrogen deficiency
◦ Testosterone deficiency in men (not as severe)

Men are therefore also at r
Secondary causes:
◦
◦
◦
◦
◦
◦
Endocrine (hyperthyroidism, hyperparathyroidism)
myeloma is a
Cancer (multiple myeloma increases osteoclasts) Multiple
bones/bone loss - the
Malabsorption (anorexia, cystic fibrosis)
Alcoholism prob multifactorial - alcohol and poor diet.
Corticosteroids steroids decrease bone mass.
Prolonged medication use (anti-convulsants, steroids)
SHIRLEY

Manifested by:
◦ Thin outer cortex
◦ Loss of trabeculae


Painless until fracture occurs
Vertebral compression fracture
◦ Wedging and collapse of vertebrae lead to kyphosis
and loss of height


Hip fracture
Once a fracture has occurred, risk of a second
fracture is much greater
femoral neck is the most common spot.
wrist fracture is common too.
Osteoporotic Fractures
www.nlm.nih.gov/.../ency/fullsize/18026.jpg
www.isbe.man.ac.uk/~mgr/fracsoln.jpg


Diagnosis with bone mineral density (BMD)
scan which scans hip and lumbar spine
Prevention is important:
◦ Regular weight bearing exercise
◦ Calcium and vitamin D intake

Treatment: both of the above and possibly
◦ Estrogen
◦ Calcitonin
◦ Bisphosphonates: most effective, inhibit osteoclast
activity
◦ Prevention of falls
Minimally effective...will decrease pain after fracture, however.
Phosomax, Boniva, etc. Inhib clasts, try to bring balance back in. Lets the blasts catch up, but
you need the Calcium, Magnesium, Vitamin D to build the bone.
Need to be counseling them on fall prevention - no loose rugs,
trim pieces on the carpet, railings on stairs, bars in the shower, etc.
PT to increase strength.
Adults


Children
Softening of the bones without loss of bone
matrix
Causes: inadequate calcium absorption, reduced
vitamin D action
◦ Can occur in renal failure due to inability of the kidney
to activate vitamin D




Symptoms: bone pain, fractures, muscle
weakness
Diagnosed through labs, x-rays
Treated with correcting the underlying cause and
adequate calcium & vitamin D
Rickets (children): dietary (non-fortified milks)
and inadequate sun exposure, can be
<--Marthos!
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Progressive disorder with excessive bone
destruction and structural changes of long
bones, spine, pelvis and skull
The second most common bone disorder
Mid-adulthood at onset with increased risk
with increasing age
Cause unknown (?viral)
Increased osteoclast activity with rapid bone
resorption and irregular bone formation
resulting in thick coarse bone with rough and
pitted outer surface
after osteoporosis.
resorption
reforming,
looks like
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Can be mild or severe
Many people may be asymptomatic
Skull: headaches, tinnitus, hearing loss
Spine: kyphosis
Bowing of tibia and femur
Pathologic fractures (femur, spine, pelvis)
Cardiovascular disease is the most common
cause of death in those with advanced disease.
Caused by increased blood flow to affected
tissues causing high-output cardiac failure
Osteogenic sarcomas occur in 5-10% of severe
cases (femur, pelvis, humerus, tibia)
Another cause of pathologi
Lots of new
bone growth
areas and g


Diagnosed on x-ray and through labs and
sometimes bone biopsy (if there is a concern
for malignancy)
Treatment:
◦ Reduce pain
◦ Suppress with calcitonin, bisphosphonates (most
effective)
◦ Adequate calcium and vitamin D
decrease osteoclasts--used for osteoporosis too.
alk-phosp
Paget Disease of the Bone
uwmsk.org/static/residentprojects/paget8511.jpg
myweb.lsbu.ac.uk/.../456-842-1641250.jpg
elastic/nonelastic
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Characteristics of intracellular fibers, cartilage
and bone
Bone cells and their purposes
Hormonal control of bone formation
Know table 56-2 (Actions of PTH, Calcitonin
and Vitamin D
Types of joints, blood and nerve supplies
What are bursae and menisci?
Define different types of soft tissue injuries
4 types of bone cells to know
Think of this simply: what is the general action of types of D, where do you g



know why you get refe
hematoma, contusion, etc.

Difference between strains and sprains (sites,
complication of sprains)
Causes of dislocations
Common knee injuries
Common shoulder injuries
Stages of fracture healing, complications of
fractures
Types and causes of osteomyelitis and risks
for osteomyelitis
Corticosteroids can cause osteonecrosis
know that avulsion frac complication of sprain
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risk factor
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Name hereditary skeletal disorders
Know causes, associated risk factor and
symptoms of juvenile disorders
Define scoliosis
Osgood, etc.
◦ Idiopathic most common and more in girls
◦ When is it treated

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<--know
Osteoporosis-causes and risks, location of
fractures
Define osteomalacia
Paget- symptoms, cellular changes, bone
changes, sites, cardiovascular changes, sarcomas
<--the big thing in
about osteoporosis.
and that it increases risk for card