Skeletal System

Anterior View of the skeletal system

Posterior View of the skeletal system

The Skeletal System serves many important functions; it provides the shape and form for our bodies in addition to supporting, protecting, allowing bodily movement, producing blood for the body, and storing minerals. Functions Its 206 bones form a rigid framework to which the softer tissues and organs of the body are attached. Vital organs are protected by the skeletal system. The brain is protected by the surrounding skull as the heart and lungs are encased by the sternum and rib cage. Bodily movement is carried out by the interaction of the muscular and skeletal systems. For this reason, they are often grouped together as the musculo-skeletal system. Muscles are connected to bones by tendons. Bones are connected to each other by ligaments. Where bones meet one another is typically called a joint. Muscles which cause movement of a joint are connected to two different bones and contract to pull them together. An example would be the contraction of the biceps and a relaxation of the triceps. This produces a bend at the elbow. The contraction of the triceps and relaxation of the biceps produces the effect of straightening the arm. Blood cells are produced by the marrow located in some bones. An average of 2.6 million red blood cells are produced each second by the bone marrow to replace those worn out and destroyed by the liver. Bones serve as a storage area for minerals such as calcium and phosphorus. When an excess is present in the blood, buildup will occur within the bones. When the supply of these minerals within the blood is low, it will be withdrawn from the bones to replenish the supply.

Types of Bone The bones of the body fall into four general categories: long bones, short bones, flat bones, and irregular bones. Long bones are longer than they are wide and work as levers. The bones of the upper and lower extremities (ex. humerus, tibia, femur, ulna, metacarpals, etc.) are of this type. Short bones are short, cube-shaped, and found in the wrists and ankles. Flat bones have broad surfaces for protection of organs and attachment of muscles (ex. ribs, cranial bones, bones of shoulder girdle). Irregular bones are all others that do not fall into the previous categories. They have varied shapes, sizes, and surfaces features and include the bones of the vertebrae and a few in the skull.

Bone Composition Bones are composed of tissue that may take one of two forms. Compact, or dense bone, and spongy, or cancellous, bone. Most bones contain both types. Compact bone is dense, hard, and forms the protective exterior portion of all bones. Spongy bone is inside the compact bone and is very porous (full of tiny holes). Spongy bone occurs in most bones. The bone tissue is composed of several types of bone cells embedded in a web of inorganic salts (mostly calcium and phosphorus) to

give the bone strength, and collagenous fibers and ground substance to give the bone flexibility.

Bone remodeling Bone remodeling is a life long process where old bone is removed from the skeleton (a sub-process called bone resorption) and new bone is added (a subprocess called bone formation). These processes also control the reshaping or replacement of bone during growth and following injuries. Remodeling responds to functional demands and muscle attachments. As a result bone is added where needed and removed where it is not required. In the first year of life, almost 100% of the skeleton is replaced. In adults, remodeling proceeds at about 10% per year. An imbalance in the regulation of bone remodeling's two sub-processes, bone resorption and bone formation, results in many metabolic bone diseases, such as osteoporosis.

Bone Repair

Skeletal Diseases Growth & Developmental Disorders

Gigantism - is abnormally large growth due to an excess of growth hormone during childhood, before the bone growth plates have closed.

Robert Wadlow at the middle w/ gigantism

Causes The most common cause of too much growth hormone release is a non-cancerous (benign) tumor of the pituitary gland. Other causes include: Carney complex, McCune-Albright syndrome (MAS), Multiple endocrine neoplasia type 1 (MEN-1), and Neurofibromatosis. Symptoms The child will grow in height, as well as in the muscles and organs. This excessive growth makes the child extremely large for his or her age. Other

symptoms include: Delayed puberty, Double vision or difficulty with side (peripheral) vision, Frontal bossing and a prominent jaw, Headache, Increased sweating, Irregular periods (menstruation), Large hands and feet with thick fingers and toes, Release of breast milk, Thickening of the facial features and Weakness. Diagnosis • CT or MRI scan of the head showing pituitary tumor • Failure to suppress serum growth hormone (GH) levels after an oral glucose challenge (maximum 75g) • High prolactin levels • Increased insulin growth factor-I (IGF-I) levels Treatment In pituitary tumors with well-defined borders, surgery is the treatment of choice and can cure many cases. For situations in which surgery cannot completely remove the tumor, medication is the treatment of choice. The most effective medications are somatostatin analogs (such as octreotide or long-acting lanreotide), which reduce growth hormone release. Dopamine agonists (bromocriptine mesylate, cabergoline) have also been used to reduce growth hormone secretion, but these are generally less effective. A medication that blocks the effect of growth hormone, pegvisomant, has recently become available. Radiation therapy has also been used to bring growth hormone levels to normal. However, it can take 5-10 years for the full effects to be seen and almost always leads to low levels of other pituitary hormones. Most experts will use radiation only if surgery and medication fail.

Dwarfism - refers to a condition in individual plants or animals characterized by extreme small size. In older popular and medical usage, any type of marked human smallness could also be termed dwarfism. The term as related to human beings (the major subject of this article) is often used to refer specifically to those forms of extreme shortness characterized by disproportion of body parts, typically due to an inheritable disorder in bone or cartilage development.

A 7 pounds girl at age of 2 Primordial Dwarfism.

Causes Most dwarfism-related conditions are genetic disorders, but the causes of some disorders are unknown. Most occurrences of dwarfism result from a random genetic mutation in either the father's sperm or the mother's egg — rather than being in one of the parent's complete genetic makeup.

Diagnosis Unusually short stature for a child's age is usually what brings the child to medical attention. Skeletal dysplasia ("dwarfism") is usually suspected because of obvious physical features (e.g., unusual configuration of face or shape of skull), because of an obviously affected parent, or because body measurements (arm span, upper to lower segment ratio) indicate disproportion. Bone x-rays are often the key to diagnosis of a specific skeletal dysplasia, but they are not the key diagnosis. Treatments Most dwarfism treatments don't increase stature but may alleviate problems caused by complications. Common surgical treatments Surgical procedures that may correct problems with bones in people with disproportionate dwarfism include: • Inserting metal staples into the ends of long bones where growth occurs (growth plates) in order to correct the direction in which bones are growing • Dividing a limb bone, straightening it and inserting metal plates to hold it in place • Inserting rods or staples to help correct the shape of the spine • Increasing the size of the opening in bones of the spine (vertebrae) to alleviate pressure on the spinal cord

Rickets- is a softening of the bones in children potentially leading to fractures and deformity. Rickets is among the most frequent childhood diseases in many developing countries. Cause The predominant cause is a vitamin D deficiency, but lack of adequate calcium in the diet may also lead to rickets. Although it can occur in adults, the majority of cases occur in children suffering from severe malnutrition, usually resulting from famine or starvation during the early stages of childhood. Symptoms: • o o o o • o o o o o

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Bone pain or tenderness Arms Legs Spine Pelvis Skeletal deformities Bowlegs Forward projection of the breastbone (pigeon chest) Bumps in the rib cage (rachitic rosary) Asymmetrical or oddshaped skull Spine deformities (spine curves abnormally, including scoliosis or kyphosis) Pelvic deformities Increased tendency toward bone fractures

• Dental deformities o Delayed formation of teeth o Defects in the structure of teeth, holes in the enamel o Increased incidence of cavities in the teeth (dental caries) o Progressive weakness o Decreased muscle tone (loss of muscle strength) Diagnosis A doctor may diagnose rickets by: • Blood tests: • Serum calcium may show low levels of calcium, serum phosphorus may be low, and serum alkaline phosphatase may be high. • Arterial blood gases may reveal metabolic acidosis • X-rays of affected bones may show loss of calcium from bones or changes in the shape or structure of the bones. • Bone biopsy is rarely performed but will confirm rickets.

Young child Legs X-ray w/ rickets

Treatment The treatment and prevention of rickets is known as antirachitic.

Bacterial Infection

Osteomyelitis

- is an infection of bone or bone marrow, usually caused by pyogenic bacteria or mycobacteria. It can be usefully subclassified on the basis of the causative organism, the route, duration and anatomic location of the infection.

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Chronic fatigue Drainage from an open wound near the area of the infection Fever, sometimes

Causes Staphylococcus aureus is the organism most commonly isolated from all forms of osteomyelitis. Symptoms Signs and symptoms of osteomyelitis depend on whether the condition is acute, lasting several months or less, or chronic, lasting several months to years. Signs and symptoms of acute osteomyelitis include: • Fever that may be abrupt • Irritability or lethargy in young children • Pain in the area of the infection • Swelling, warmth and redness over the area of the infection Signs and symptoms of chronic osteomyelitis include: • Warmth, swelling and redness over the area of the infection • Pain or tenderness in the affected area

Osteomyelitis of the tibia of a young child. Numerous abscesses in the bone show as radiolucency.

Diagnostic The process of diagnosing a spinal infection usually starts with an x-ray. Xrays will usually be normal in the first 2 to 4 weeks after the infection starts. For changes to show up on an x-ray, 50% to 60% of the bone in the vertebral body needs to be destroyed. If the disc space is involved (discitis), the disc space may narrow and destruction of the endplates around the disc may be seen on the x-ray. The most sensitive and specific imaging study for spinal infection is a MRI scan with enhancement with an intravenous dye (Gadolinium). The infection will cause an increase in blood flow to the vertebral body, and this will be picked up by the Gadolinium, which will enhance the MRI signal in areas of increased blood flow.

Treatment Osteomyelitis often requires prolonged antibiotic therapy, with a course lasting a matter of weeks or-months. A PICC line or central venous catheter is often placed for this purpose. Osteomyelitis also may require surgical debridement. Severe cases may lead to the loss of a limb. Initial first line antibiotic choice is determined by the patient's history and regional differences in common infective organisms.

painless mass. Some bone tumors may weaken the structure of the bone, causing pathologic fractures.

Tumors

Bone tumor - is an inexact term, which can be used for both benign and malignant abnormal growths found in bone, but is most commonly used for primary tumors of bone, such as osteosarcoma (or osteoma). It is less exactly applied to secondary, or metastatic tumors found in bone. Causes The cause of bone tumors is unknown. They often arise in areas of rapid growth. Possible causes include: • Inherited genetic mutations • Radiation • Trauma Symptoms The most common symptom of bone tumors is pain, but many patients will not experience any symptoms, except for a

Thighbone (femur) tumor. The X-ray shows a bone tumor in the middle of the thighbone. The tumor is also seen using magnetic resonance imaging (MRI). The insert at the top shows a coronal MRI. The insert at the bottom shows a cross sectional MRI. The arrows on all images show the location of the tumor.

Diagnosis The doctor will collect detailed information about general health and the tumor's type, size, location, and possible extent of spread. Medical HistoryThe doctor will need to take a complete medical history. This includes learning about any medications you take, details about any previous tumors or cancers that you or your family members may have had, and symptoms you are experiencing. Physical ExaminationYour doctor will physically examine you. The focus is on the tumor mass, tenderness in bone, and any impact on joints and/or range of motion. In some

cases, the doctor may want to examine other parts of your body to rule out cancers that can spread to bone. ImagingYour doctor will probably obtain X-rays. Different types of tumors have different characteristics on X-ray. Treatment Treatment of bone tumors is highly dependent on the type of tumor.

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Symptoms In the early stages, you may have no osteomalacia symptoms, although signs of osteomalacia may be apparent on Xray pictures or other diagnostic tests. As osteomalacia worsens, symptoms may include: •

Decalcification

Osteomalacia - is the general term for the softening of the bones due to defective bone mineralization. Osteomalacia in children is known as rickets, and because of this, osteomalacia is often restricted to the milder, adult form of the disease. It may show signs as diffuse body pains, muscle weakness, and fragility of the bones.

Chronic renal failure Therapy with Fumaderm

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Bone pain. People with osteomalacia often experience pain in their bones, especially in the lower spine, pelvis and legs and feet. Pain associated with osteomalacia is usually dull and aching and worsens during physical activity. You might notice that gently pressing on a bone — on your shin, for example — produces severe pain. Muscle weakness. Osteomalacia can cause weakness or stiffness in your arms and legs, decreased muscle tone and discomfort while moving. Some people with osteomalacia walk with a waddling motion.

Cause The causes of adult osteomalacia are varied. • Insufficient sunlight exposure, especially in dark-skinned subjects • Insufficient nutritional quantities or faulty metabolism of vitamin D or phosphorus • Renal tubular acidosis • Malnutrition during pregnancy • Malabsorption syndrome

A young male with osteomalacia. Note a pseudofracture in the medial edge of the upper femoral shaft (arrow).

Diagnosis To make a diagnosis of osteomalacia, your doctor will likely ask you about your symptoms, the amount of time that you spend in the sun and your diet. In order to rule out other bone disorders, such as osteoporosis, you may undergo one or more of the following tests: •

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Blood and urine tests. In cases of osteomalacia caused by vitamin D deficiency or by phosphorus loss, abnormal levels of vitamin D and the minerals calcium and phosphorus are often detected. X-ray. Slight cracks in your bones that are visible on X-rays, referred to as Looser transformation zones, are a characteristic feature of people with osteomalacia. Bone scan. This procedure detects areas of increased and decreased bone metabolism in your body. During this test, a radioactive dye is injected into a vein and a camera takes pictures of how much radioactive dye collects in your bones. If you have osteomalacia, the radioactive dye may

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appear to be unevenly distributed in some areas of your bones. Bone biopsy. During a bone biopsy, your doctor inserts a slender needle through your skin and into your bone to withdraw a small sample for viewing under a microscope. Although a bone biopsy is very accurate in detecting osteomalacia, it's not often needed to make the diagnosis.

Treatment Nutritional osteomalacia responds well to administration of 200,000 IU weekly of vitamin D for 4 to 6 weeks, followed by a maintenance dose of 1600 IU daily or 200,000 IU every 4 to 6 months.

Osteoporosis - is a disease of bone that leads to an increased risk of fracture. In osteoporosis the bone mineral density (BMD) is reduced, bone microarchitecture is disrupted, and the amount and variety of non-collagenous proteins in bone is altered. Cause There is no single cause of osteoporosis. Our bodies constantly build new bone and remove older bone. In childhood, more bone is built than removed, and so the bones grow in size. After age 30 or 40, however, the cells that build new bone do not keep up with those that remove bone. The total amount of bone then decreases, and osteoporosis may develop as a result. Symptoms Osteoporosis itself has no specific symptoms; its main consequence is the increased risk of bone fractures. Osteoporotic fractures are those that occur in situations where healthy people would not normally break a bone; they are therefore regarded as fragility

fractures. Typical fragility fractures occur in the vertebral column, rib, hip and wrist.

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a bone density test to detect low bone density.

Before performing any tests, your doctor will record information about your medical history and lifestyle and will ask questions related to: • risk factors, including information about any fractures you have had • your family history of disease, including osteoporosis • medication history • general intake of calcium and vitamin D • exercise pattern • for women, menstrual history. X- ray lateral view of Vertebrae

Diagnosis Osteoporosis is a condition of low bone density that can progress silently over a long period of time. If diagnosed early, the fractures associated with the disease can often be prevented. Unfortunately, osteoporosis frequently remains undiagnosed until a fracture occurs. An examination to diagnose osteoporosis can involve several steps that predict your chances of future fracture, diagnose osteoporosis, or both. It might include: • an initial physical exam • various x rays that detect skeletal problems • laboratory tests that reveal important information about the metabolic process of bone breakdown and formation

In addition, the doctor will note medical problems and medications you may be taking that can contribute to bone loss (including glucocorticoids, such as cortisone). He or she will also check your height for changes and your posture to note any curvature of the spine from vertebral fractures, which is known as kyphosis. Treatment The primary goal of treatment of osteoporosis is to reduce the risk of pathologic fractures. The three mainstays of treatment are: • Weight-bearing exercise • Nutrition supplementation • Medications

Bone Fractures

Fractures A fracture is commonly referred to as a broken bone. Fractures are common; the average person has two during a lifetime. They occur when the physical force exerted on the bone is stronger than the bone itself. Your risk of fracture depends, in part, on your age. Broken bones are very common in childhood, though children's fractures are generally less complicated than fractures in adults. Older people, whose bones are more brittle, are more likely to suffer fractures from falls that would not affect younger people. There are many types of fractures, but the main categories are complete, incomplete, compound and simple. Complete and incomplete fractures refer to the way the bone breaks: In a complete fracture, the bone snaps into two or more parts; in an incomplete fracture, the bone cracks but does not break all the way through. In a compound fracture, also called an open fracture, the bone breaks through the skin; it may then recede back into the wound and not be visible through the skin. In a simple fracture, also called a closed fracture, the bone breaks but there is no open wound in the skin.

Simple fractures include:

Comminuted fracture Greenstick Fracture.

Greenstick fracture: an incomplete fracture in which the bone is bent. This type occurs most often in children.

Comminuted fracture: a fracture in which the bone fragments into several pieces.

Transverse fracture

Transverse fracture: a fracture at a right angle to the bone's axis.

Oblique fracture

Oblique fracture: a fracture in which the break slopes.

Buckle fracture of the distal radius. Arrows indicate location of fracture.

Impacted fracture: is one whose ends are driven into each other. This is commonly seen in arm fractures in children and is sometimes known as a buckle fracture. Other types of fracture are pathologic fracture, caused by a disease that weakens the bones, and stress fracture, a hairline crack. Other types of fracture: are pathologic fracture, caused by a disease that weakens the bones, and stress fracture, a hairline crack.

Joint A joint is the location at which two or more bones make contact. They are constructed to allow movement and provide mechanical support, and are classified structurally and functionally. Classification Joints are mainly classified structurally and functionally. Structural classification is determined by how the bones connect to each other, while functional classification is determined by the degree of movement between the articulating bones. In practice, there is significant overlap between the seven types of classifications. Terms ending in the suffix -sis are singular and refer to just one joint, while -ses is the suffix for pluralization. Structural classification Structural classification names and divides joints according to how the bones are connected to each other. There are three structural classifications of joints: • • •

fibrous joint - joined by fibrous connective tissue cartilaginous joint joined by cartilage synovial joint - not directly joined

Functional classification Joints can also be classified functionally, by the degree of mobility they allow: •

synarthrosis - permits little or no mobility.

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Most synarthrosis joints are fibrous joints (eg The Skull). amphiarthrosis - permits slight mobility. Most amphiarthrosis joints are cartilaginous joints (eg. Vertabrae). diarthrosis - permits a variety of movements. All diarthrosis joints are synovial joints (eg. Shoulder, Hip, Elbow, Knee etc), and the terms "diarthrosis" and "synovial joint" are considered equivalent by Terminologia Anatomica.

Joint Disorders Arthritis

Arthritis (from Greek arthro-, joint + -itis, inflammation; plural: arthritides) is a group of conditions involving damage to the joints of the body. Arthritis is the leading cause of disability in people older than fifty-five years. Cause Determining the cause of arthritis can be difficult, because often several factors contribute to an individual developing this common problem. Some of the risk factors that can cause arthritis include: Genetics Exactly how much heredity or genetics contributes to the cause of arthritis is not well understood. However, there are likely genetic variations that can contribute to the cause of arthritis. Age Cartilage becomes more brittle with age and has less of a capacity to repair itself. As people grow older they are more likely to develop arthritis. Weight Because joint damage is partly dependent on the load the joint has to support, excess body

weight can lead to arthritis. This is especially true of the hips and knees that can be worn quickly in heavier patients. Previous Injury Joint damage can cause irregularities in the normal smooth joint surface. Previous major injuries can be part of the cause of arthritis. An example of an injury leading to arthritis is a tibial plateau fracture, where the broken area of bone enters the cartilage of the knee joint. Occupational Hazards Workers in some specific occupations seem to have a higher risk of developing arthritis than other jobs. These are primarily high demand jobs such as assembly line workers and heavy construction. Some High-Level Sports It is difficult to determine how much sports participation contributes to development of arthritis. Certainly, sports participation can lead to joint injury and subsequent arthritis. However, the benefits of activity likely outweigh any risk of arthritis. Illness or Infection People who experience a joint infection (septic joint), multiple episodes of gout, or other medical conditions, can develop arthritis of the joint. Symptoms Joint pain and progressive stiffness without noticeable swelling, chills, or fever during normal activities probably indicate the gradual onset of osteoarthritis.

Diagnosis Arthritis diagnosis information, blood tests, and other diagnostic tests. Physical examination and diagnostic tests, along with a patient's clinical picture, help to formulate an accurate diagnosis. Arthrography - is an imaging technique that utilizes contrast dye so that certain structures of the joints that aren't readily seen on traditional X-rays can be seen. Arthrography helps detect joint damage and problems with surrounding structures. Arthritis is a complicated disease with many different types. To accurately diagnose arthritis, a medical history, physical examination, laboratory tests, and medical imaging are involved.

targeted at the disease process causing the arthritis). Arthroplasty (joint replacement surgery) may be required in eroding forms of arthritis. In general, studies have shown that physical exercising of the affected joint can have noticeable improvement in terms of long-term pain relief. Furthermore, exercising of the arthritic joint is encouraged to maintain the health of the particular joint and the overall body of the person. Another form of non-drug treatment that does have a body of proper research to support its efficacy is marine oil, from both fish and the New Zealand greenlipped mussel (Perna canaliculus). Diets high in marine oils from cold-water fish such as salmon, mackerel, and tuna have been shown to reduce the inflammation of joint conditions such as arthritis. Massage on joints with neem oil has reported improvement in chronic and acute cases

Rheumatoid arthritis (RA) is a chronic, systemic autoimmune disorder that causes the immune system to attack the joints, where it causes inflammation (arthritis) and destruction. It can also damage some organs, such as the lungs and skin. It can be a disabling and painful condition, which can lead to substantial loss of functioning and mobility.

Patient hands X-ray-Arthritis

Treatment Treatment options vary depending on the type of arthritis and include physical and occupational therapy, lifestyle changes (including exercise and weight control), medications and dietary supplements (symptomatic or

Cause The cause of rheumatoid arthritis is a very active area of worldwide research. Some scientists believe that the tendency to develop rheumatoid arthritis may be genetically inherited. It is suspected that certain infections or factors in the environment might trigger the immune system to attack the body's own tissues, resulting in inflammation in various organs of the body such as the lungs or eyes.

Regardless of the exact trigger, the result is an immune system that is geared up to promote inflammation in the joints and occasionally other tissues of the body. Immune cells, called lymphocytes, are activated and chemical messengers (cytokines, such as tumor necrosis factor/TNF and interleukin-1/IL-1) are expressed in the inflamed areas. Environmental factors also seem to play some role in causing rheumatoid arthritis. Recently, scientists have reported that smoking tobacco increases the risk of developing rheumatoid arthritis. Symptoms While rheumatoid arthritis primarily affects joints, problems involving all other organs of the body are known to occur. Extra-articular ("outside the joints") manifestations occur in about 15% of individuals with rheumatoid arthritis. It can be difficult to determine whether disease manifestations are directly caused by the rheumatoid process itself, or from side effects of the medications commonly used to treat it - for example, lung fibrosis from methotrexate, or osteoporosis from corticosteroids.

Diagnosis It is diagnosed with blood tests (especially a test called rheumatoid factor) and X-rays. Diagnosis and longterm management are typically performed by a rheumatologist, an expert in the diseases of joints and connective tissues.

If one metacarpal phalangeal joint (MCP) is involved with rheumatoid arthritis, then typically all of the joints are involved. In this image we see that every MCP joint is affected. The DIP (distal interphalangeal) joints are relatively spared. This patient has also developed ligamentous abnormalities due to RA. A radial deviation of the carpus and ulnar deviation of the digits give the hands a characteristic zig-zag pattern.

Treatment There is no known cure for rheumatoid arthritis, but many different types of treatment can alleviate symptoms and/or modify the disease process. The goal of treatment is two-fold: alleviating the current symptoms, and preventing the future destruction of the joints with the resulting handicap if the disease is left unchecked. These two goals may not always coincide: while pain relievers may achieve the first goal, they do not have any impact on the long-term consequences. For these reasons, most authorities believe that most RA should be treated by at least one specific antirheumatic medication, also named DMARD (Disease modifying anti-rheumatic drugs) reduces the rate of damage to bone and cartilage.

Degenerative Joint Disease

Osteoarthritis (OA, also known as degenerative arthritis, degenerative joint disease), is a clinical syndrome in which low-grade inflammation results in pain in the joints, caused by abnormal wearing of the cartilage that covers and acts as a cushion inside joints and destruction or decrease of synovial fluid that lubricates those joints. As the bone surfaces become less well protected by cartilage, the patient experiences pain upon weight bearing, including walking and standing. Due to decreased movement because of the pain, regional muscles may atrophy, and ligaments may become more lax. OA is the most common form of arthritis and the leading cause of chronic disability in the United States. Osteoarthritis" is derived from the Greek word "osteo", meaning "of the bone", "arthro", meaning "joint", and "itis", meaning inflammation, although many sufferers have little or no inflammation. Causes Although it commonly arises from trauma, osteoarthritis often affects multiple members of the same family, suggesting that there is hereditary susceptibility to this condition. A number of studies have shown that there is a greater prevalence of the disease between siblings and especially identical twins, indicating a

hereditary basis. Up to 60% of OA cases are thought to result from genetic factors. Researchers are also investigating the possibility of allergies, infections, or fungi as a cause. There is some evidence that allergies, whether fungal, infectious or systemically induced, may be a significant contributing factor to the appearance of osteoarthritis in a synovial sac. In osteoarthritis, the joint cartilage breaks down. Cartilage exists within the incudomalleolar and incudostapedial joints. In addition, the cartilage-covered base of the stapes footplate is bound to the cartilage-covered rim of the oval window by the annular ligament. Thus, higher prevalence of middle ear abnormalities and hearing loss can be expected in osteoarthritis due to degeneration of the cartilage and the subsequent abnormal repair response. Osteoarthritis and hearing loss are considered among the top chronic health concerns in older individuals although the connection between these two conditions has not been previously reported. Primary This type of OA is a chronic degenerative disorder related to but not caused by aging, as there are people well into their nineties who have no clinical or functional signs of the disease. Secondary This type of OA is caused by other factors or diseases but the resulting pathology is the same as for primary OA: Congenital disorders, such as: Congenital hip luxation, Cracking joints, Diabetes, Obesity and Hormonal disorders

careful study of the duration, location, the character of the joint symptoms, and the appearance of the joints themselves. As yet, there are no methods available to detect OA in its early and potentially treatable stages. Treatment Generally speaking, the process of clinically detectable osteoarthritis is irreversible, and typical treatment consists of medication or other interventions that can reduce the pain of OA and thereby improve the function of the joint. Conservative care Knee X-ray of a person w/ Osteoarthritis.

Diagnosis Diagnosis is normally done through x-rays. This is possible because loss of cartilage, subchondral ("below cartilage") sclerosis, subchondral cysts from synovial fluid entering small microfractures under pressure, narrowing of the joint space between the articulating bones, and bone spur formation (osteophytes) - from increased bone turnover in this inflammatory condition, show up clearly on x-rays. Plain films, however, often do not correlate well with the findings of physical examination of the affected joints.

No matter the severity or location of OA, conservative measures such as weight control, appropriate rest and exercise, and the use of mechanical support devices are usually beneficial. In OA of the knees, knee braces, a cane, or a walker can be helpful for walking and support. Regular exercise, if possible, in the form of walking or swimming, is encouraged. Applying local heat before, and cold packs after exercise, can help relieve pain and inflammation, as can relaxation techniques. Heat - often moist heat -eases inflammation and swelling, and may improve circulation, which has a healing effect on the local area. Weight loss can relieve joint stress and may delay progression. Proper advice and guidance by a health care provider is important in OA management, enabling people with this condition to improve their quality of life. Medical treatment

With or without other techniques, such as MRI (magnetic resonance imaging), arthrocentesis and arthroscopy, diagnosis can be made by a

Medical treatment includes NSAIDs, local injections of glucocorticoid or hyaluronan, and in severe cases, with joint replacement surgery. There has been

no cure for OA, as cartilage has not been induced to regenerate. However, if OA is caused by cartilage damage (for example as a result of an injury) Autologous Chondrocyte Implantation may be a possible treatment. Clinical trials employing tissue-engineering methods have demonstrated regeneration of cartilage in damaged knees, including those that had progressed to osteoarthritis. Further, in January 2007, Johns Hopkins University was offering to license a technology of this kind, listing several clinical competitors in its market analysis. Dietary Supplements which may be useful for treating OA include: Glucosamine -A molecule derived from glucosamine is used by the body to make some of the components of cartilage and synovial fluid. Supplemental glucosamine may improve symptoms of OA and delay its progression. Chondroitin -Along with glucosamine, chondroitin sulfate has become a widely used dietary supplement for treatment of osteoarthritis. A meta-analysis of randomized controlled trials found no benefit from chondroitin.

Gout

Gout (also called metabolic arthritis) is a disease created by a buildup of uric acid. In this condition, monosodium urate or uric acid crystals are deposited on the articular cartilage of joints, tendons and surrounding tissues due to elevated concentrations of uric acid in the bloodstream. This provokes an inflammatory reaction of these tissues. Cause Gout is caused by too much uric acid in the blood (hyperuricemia). Hyperuricemia usually does no harm, and most people with high levels of uric acid in the blood never develop gout. The exact cause of hyperuricemia sometimes goes undiscovered, although inherited factors (genes) seem to play a role. When uric acid levels in the blood are too high, uric acid may form crystals that accumulate in the joints. Symptoms Gout is characterized by excruciating, sudden, unexpected, burning pain, as well as swelling, redness, warmth, and stiffness in the affected joint. This occurs commonly in men in their toes but can appear in other parts of the body and affects women as well. Low-grade fever may also be present. The patient usually suffers from two sources of pain. The crystals inside the joint cause intense pain whenever the affected area is moved. The inflammation of the tissues around the joint also causes the skin to be swollen, tender and sore if it is even slightly touched. For example, a blanket or even the lightest sheet draping over the affected area could cause extreme pain. Gout usually attacks the big toe (approximately 75 percent of first attacks); however, it also can affect other

joints such as the ankle, heel, instep, knee, wrist, elbow, fingers, and spine. In some cases, the condition may appear in the joints of small toes that have become immobile due to impact injury earlier in life, causing poor blood circulation that leads to gout.

Arthrocentesis: A more reliable method of diagnosis uses arthrocentesis. Using a syringe and needle a synovial fluid sample is taken from an affected joint. The synovial fluid is analysed under a microscope. The presence of monosodium urate (MSU) crystals in the fluid indicates the presence of gout.

Diagnosis Physical examination and review of medical history: Diagnosis usually begins with a review of family medical history and a physical examination. The presence of tophi below the skin and red shiny skin above the affected area can indicate gout. However a more thorough medical examination is required to eliminate the other conditions listed above. Blood test: A blood test can be used to measure levels of uric acid in the blood. This is not a reliable method for diagnosing gout. During a gout attack blood uric acid levels can lie within the normal range. Also, high uric acid levels don't always indicate the presence of gout. X-rays: X-rays can be taken to show tophi crystals around the joints and under the skin. However, X-rays of affected joints often show the joints to be normal so may not help in the diagnosis.

Showing multiple erosion locations including first MTP, base of third and fourth metacarpals, and possibly the head of the fifth metacarpal and second proximal phalanx.

Treatment Acute attacks The first line of treatment should be pain relief. Once the diagnosis has been confirmed, the drugs of choice are indomethacin, other nonsteroidal antiinflammatory drugs (NSAIDs), oral glucocorticoids, or intra-articular glucocorticoids administered via a joint injection.

Colchicine was previously the drug of choice in acute attacks of gout, as it impairs the motility of granulocytes and can prevent the inflammatory phenomena that initiate an attack. Colchicine should be taken within the first 12 hours of the attack and usually relieves the pain within 48 hours, although side effects (gastrointestinal upset such as diarrhea and nausea) can complicate its use. NSAIDs are the preferred form of analgesia for patients with gout. A randomized controlled trial found similar benefit from nonsteroidal anti-inflammatory drugs and oral glucocorticoids; however, less adverse drug reactions occurred in the glucocorticoids group. In the nonsteroidal anti-inflammatory drugs group, each patient initially received diclofenac (75 mg) intramuscularly, indomethacin 50 mg orally, and acetaminophen 1 g orally. The patient was received a 5-days of indomethacin (50 mg orally every 8 hours for 2 days, followed by indomethacin 25 mg every 8 hours for 3 days), and acetaminophen 1 g every 6 hours as needed. The glucocorticoids patients received prednisolone 30 mg orally, and acetaminophen 1 g orally. The patient was then given prednisolone 30 mg orally once per day for five days. Chronic joint changes

For extreme cases of gout, surgery may be necessary to remove large tophi and correct joint deformity. Bursitis and Bunions

Bursitis is the inflammation of one or more bursae (small sacs) of synovial fluid in the body. The bursae rest at the points where internal functionaries, such as muscles and tendons, slide across bone. Healthy bursae create a smooth, almost frictionless functional gliding surface making normal movement painless. When bursitis occurs, however, movement relying upon the inflamed bursa becomes difficult and painful. Moreover, movement of tendons and muscles over the inflamed bursa aggravates its inflammation, perpetuating the problem. Causes Bursitis is commonly caused by repetitive movement and excessive pressure. Elbows and knees are the most commonly affected. Inflammation of the bursae might also cause other inflammatory conditions such as rheumatoid arthritis. Although infrequent, scoliosis might cause bursitis of the shoulders, however, shoulder bursitis is more commonly caused by overuse of the shoulder joint and related muscles. Traumatic injury is another cause of bursitis. The inflammation irritates because the bursa no longer fits in the original small area between the bone and the functionary muscle or tendon. When the bone increases pressure upon the bursa, bursitis results.

Symptoms Bursitis symptoms vary from local joint pain and stiffness, to burning pain that surrounds the joint around the inflamed bursa. In this condition, the pain usually is worse during and after activity, and then the bursa and the surrounding joint become stiff the next day in the morning. Diagnosis Bursitis is typically identified by localized pain or swelling, tenderness, and pain with motion of the tissues in the affected area. X-ray testing can sometime detect calcifications in the bursa when bursitis has been chronic or recurrent.

it requires aspiration of the bursa fluid. This procedure involves removal of the fluid with a needle and syringe under sterile conditions. It can be performed in the doctor's office. Sometimes the fluid is sent to the laboratory for further analysis. Noninfectious bursitis can also be treated with a cortisone injection into the swollen bursa. This is sometimes done at the same time as the aspiration procedure and typically rapidly reduces the inflammation of the swollen bursa. Infectious (septic) bursitis requires even further evaluation and aggressive treatment. The bursal fluid can be examined in the laboratory to identify the microbes causing the infection. Septic bursitis requires antibiotic therapy, sometimes intravenously. Repeated aspiration of the infected fluid may be required. Surgical drainage and removal of the infected bursa sac (bursectomy) may also be necessary. Generally, the adjacent joint functions normally after the surgical wound heals.

Bunion (hallux valgus) is a structural deformity of the bones and the joint between the foot and big toe, and may be painful.

Radiograph of Elbow w/ Bursitis

Treatment The treatment of any form of bursitis depends on whether or not it involves infection. Bursitis that is not infected (from injury or underlying rheumatic disease) can be treated with ice compresses, rest, and antiinflammatory and pain medications. Occasionally,

Causes People with certain foot types are more likely to develop bunions. If you have flat feet, or low arches, your chance of getting bunions is increased. Most bunions develop as a result of wearing shoes that do not fit properly. Women get bunions more often than men because they tend to wear tight, pointed, or high-heeled shoes. High heels push most of your body weight onto the front of your foot, placing a great strain on the toe joints. Women also tend to have looser ligaments than men, which make

them more prone to getting bunions. If your shoes are tight, they will rub against the big toe joint. This can thicken the skin and tissues and form a bunion. Continuing to wear badly fitting shoes will make your bunions worse. Bunions can also be caused, or made worse, by arthritis. Arthritis is a condition where the protective cartilage covering the joints becomes diseased or damaged. As the joints are stiff, and hard to move, it can be difficult to straighten out your toes to prevent them rubbing against your shoes. Symptoms The symptoms of bunions include irritated skin around the bunion, joint redness and pain, and possible shift of the big toe toward the other toes. Diagnosis Bunions cause a visible swelling at the base of the big toe. Your GP will therefore be able to identify a bunion just by looking at your foot. You may be asked to move your big toe up and down to see if your range of movement is limited. Your GP will also check for redness and swelling and ask you about pain. You may also be asked about the types of shoes that you wear and how frequently you wear them. You should tell your GP if anyone in your

family has had bunions, or if you have injured your foot in any way. An X-ray may sometimes be necessary to see how severe the bunion is and to check the alignment of your toes.

Hallux valgus .

Treatment Bunions may be treated conservatively with changes in shoe gear, different orthotics (accommodative padding and shielding), rest, ice, and medications. These sorts of treatments address symptoms more than they correct the actual deformity. Surgery, by a Podiatrist, may be necessary if discomfort is severe enough or when correction of the deformity is desired.

Divisions of the Skeleton The human skeleton is divided into two distinct parts: The axial skeleton consists of bones that form the axis of the body and support and protect the organs of the head, neck, and trunk. • • • •

The Skull The Sternum The Ribs The Vertebral Column

SKULL

Frontal view.

Side view.

The skull is the bony framework of the head. It is comprised of the eight cranial and fourteen facial bones. Cranial Bones The cranial bones makeup the protective frame of bone around the brain. The cranial bones are: •

•

•

The frontal forms part of the cranial cavity as well as the forehead, the brow ridges and the nasal cavity. The left and right parietal forms much of the superior and lateral portions of the cranium. The left and right temporal form the lateral walls of the

• • •

•

cranium as well as housing the external ear. The occipital forms the posterior and inferior portions of the cranium. Many neck muscles attach here as this is the point of articulation with the neck. The sphenoid forms part of the eye orbit and helps to form the floor of the cranium.

•

The ethmoid forms the medial portions of the

orbits and the roof of the nasal cavity.

The joints between bones of the skull are immovable and called sutures. The parietal bones are joined by the sagittal suture. Where the parietal bones meet the frontal is referred to as the coronal suture. The parietals and the occipital meet at the lambdoidal suture. The suture between the parietals and the temporal bone is referred to as the squamous suture. These sites are the common location of fontanelles or "soft spots" on a baby’s head.

the posterior portion of the roof of the mouth. • The left and right zygomatic are the cheek bones. They form portions of the orbits as well. • The left and right nasal form the superior portion of the bridge of the nose. • The left and right lacrimal help to form the orbits. • The vomer forms part of the nasal septum (the divider between the nostrils). The left and right inferior turbinate forms the lateral walls of the nose and increase the surface area of the nasal cavity.

Facial Bones The facial bones makeup the upper and lower jaw and other facial structures. The facial bones are: •

•

• •

•

The mandible is the lower jawbone. It articulates with the temporal bones at the temporomandibular joints. This forms the only freely moveable joint in the head. It provides the chewing motion. The left and right maxilla are the upper jaw bones. They form part of the nose, orbits, and roof of the mouth. The left and right palatine form a portion of the nasal cavity and

Feature Angle of jaw or mandible

Location back of jaw

Aveolar process

maxilla, root of teeth

Condyle of mandible

top of ramus of mandible

Coronal suture

top of head between frontal and parietal cranial bones between ramus of mandible and mastoid process eye cavity

External acoustic meatus Ethmoid bone Forehead boss or frontal tuberosity

forehead

Grontal bone

top of face (forehead) and front top of head

Glabella

center of forehead

Lacrimal bone Lambdoid suture

inner corner of eye socket back of head

Mandible or jaw bone

lower part of jaw

Maxilla

upper part of jaw

Mastoid process

lower part of temporal bone, behind ramus of jaw

Description the corner of the jaw where the mandible body turns upwards into the ramus. rugosities associated with tooth development. a ball-like end to the ramus of the mandible that forms a hinge with the temporal bone. one of the major joints or sutures between the plates of the frontal and parietal cranial bones. a hole in the temporal cranial bone allowing the passage of sound to enter the inner ear. a cranial bone forming part of the eye cavity. a feature of the frontal bone that forms the "bumps" in the forehead above the eyebrows. one of the major cranial bones that forms the forehead and front top of the head; roughly covers the frontal lobes of the brain. an area in the center of the forehead, between the eyebrows, that assumes various shapes on different individuals. a small bone forming a cavity for the tear gland. suture or joint between the occipital and parietal cranial bones. the lower jaw bone is the only skull bone that moves, i.e., during mastication, speech, and expression; carries the lower teeth. the two maxillae form the center of the face with many attaching muscles; carry the upper teeth; form part of the eye orbit; act like keystones into which the other facial bones fit. built up area of the lower temporal bone where important neck muscles attach.

Feature Mental protuberance

Location chin boss

Mental tuberosities

chin boss

Nasal bone

nose

Nasal concha

nasal cavity

Nasal spine

center of nose

Occipital bone

the lower rear of the head

Parietal bone

top and side of head

Ramus of mandible

Supraorbial foramen

back part of the mandible temple and eye orbit area side of head between parietal and temporal bones upper orbit of eye

Supraorbital process

eyebrows

Temporal bone

side of the head, above the ear

Temporal lines

Volmer

front part of temple and lower part of frontal bones nasal cavity

Zygomatic bone

cheek

the principal cheek bone; origin of zygomatic and other facial muscles.

Zygomatic process

bones bordering zygomatic bone

the temporal and maxilla bones have areas next to the zygomatic bone.

Sphenoid bone Squamosal suture

Description a feature of the mandible at the lower front part of the chin which underlies part of the chin boss. a dual bulbous formation of the mandible that underlies part of the chin boss. forms the upper part of the nose and nasal bridge; the lower part of the bridge is formed of cartilage. Formations creating part of the nasal cavity. feature of maxilla facial bone at center of nose to which septum is attached. a major cranial bone at the lower back of the head; covers occipital lobe of the brain. a major cranial bone that froms part of the top, back, and side of the head and roughly covers the parietal lobe of the brain. the more vertical part of the mandible. a cranial bone that forms part of the eye cavity. one of the major joints or sutures between the parietal and temporal cranial bones. a hole in the frontal bone where nerves and blood vessels pass through; forms a notch in the orbit of the eye. a formation of the frontal bone above the orbit of the eye, under and above the eyebrows that affects the appearance of the eyebrows. a cranial bone on the side of the head that roughly covers the temporal lobe of the brain; it extends down behind the ear towards the jaw. lines in the frontal bone around the temple. a facial bone on the centerline of the nose that forms part of the nasal cavity.

The Sternum

the bottom of the sternum. It is often cartilaginous (cartilage), but does become bony in later years. These three segments of bone are usually fused in adults. The sternum serves an important function in the body. The ribs are connected to it by the costal cartilage. Without the sternum, there would be a hole in the bone structure in the middle of your chest, right above your heart and lungs. The sternum protects this vital area and completes the circle of the rib cage.

The Ribs The sternum is a flat, dagger shaped bone located in the middle of the chest. Along with the ribs, the sternum forms the rib cage that protects the heart, lungs, and major blood vessels from damage. The sternum is composed of three parts: The manubrim, also called the "handle", is located at the top of the sternum and moves slightly. It is connected to the first two ribs. The body, also called the "blade" or the "gladiolus", is located in the middle of the sternum and connects the third to seventh ribs directly and the eighth through tenth ribs indirectly. The xiphoid process, also called the "tip", is located on

The ribs are thin, flat, curved bones that form a protective cage around the organs in the upper body. They are comprised 24 bones arranged in 12 pairs. These bones are divided into three categories: The first seven bones are called the true ribs. These bones are connected to the spine (the backbone) in back. In the front, the true ribs are connected directly to the breastbone or sternum by a strips of

cartilage called the costal cartilage. The next three pairs of bones are called false ribs. These bones are slightly shorter than the true ribs and are connected to the spine in back. However, instead of being attached directly to the sternum in front, the false ribs are attached to the lowest true rib. The last two sets of rib bones are called floating ribs. Floating ribs are smaller than both the true ribs and the false ribs. They are attached to the spine at the back, but are not connected to anything in the front. The ribs form a kind of cage the encloses the upper body. They give the chest its familiar shape. The ribs serve several important purposes. They protect the heart and lungs from injuries and shocks that might damage them. Ribs also protect parts of the stomach, spleen, and kidneys. The ribs help you to breathe. As you inhale, the muscles in between the ribs lift the rib cage up, allowing the lungs to expand. When you exhale, the rib cage moves down again, squeezing the air out of your lungs.

The vertebral column

The vertebral column (also called the backbone, spine, or spinal column) consists of a series of 33 irregularly shaped bones, called vertebrae. These 33 bones are divided into five categories depending on where they are located in the backbone. The first seven vertebrae are called the cervical vertebrae. Located at the top of the spinal column, these bones form a flexible framework for the neck and support the head. The first cervical vertebrae is called the atlas and the second is called the axis. The atlas' shape allows the head to nod "yes" and the axis' shape allows the head to shake "no". The next twelve vertebrae are called the thoracic vertebrae. These bones move with the ribs to form the rear anchor of the rib cage. Thoracic vertebrae are larger than cervical vertebrae and increase in size from top to bottom. After the thoracic vertebrae, come the lumbar vertebrae. These five bones are the largest vertebrae in the spinal column. These vertebrae support most of the body's weight and are attached to many of the back muscles.

The sacrum is a triangular bone located just below the lumbar vertebrae. It consists of four or five sacral vertebrae in a child, which become fused into a single bone after age 26. The sacrum forms the back wall of the pelvic girdle and moves with it. The bottom of the spinal column is called the coccyx or tailbone. It consists of 3-5 bones that are fused The appendicular skeleton is composed of bones that anchor the appendages to the axial skeleton. • • • •

The Upper Extremities The Lower Extremities The Shoulder Girdle The Pelvic Girdle--(the sacrum and coccyx are considered part of the vertebral column)

The Upper Extremities consists of three parts: the arm, the forearm, and the hand.

The Arm The arm, or brachium, is technically only the region between the shoulder and elbow. It consists of a single long bone called the humerus. The humerus is the longest bone in the upper extremity. The top, or head, is large, smooth, and rounded and fits into the scapula in the shoulder. On the bottom of the humerus, are two depressions where the humerus connects to the ulna and radius of the forearm. The radius is connected on the side away from the body (lateral side) and the ulna is connected on the side towards the body (medial side) when standing in the anatomical position. Together, the humerus and the ulna make up the elbow. The bottom of the humerus protects the ulnar nerve and is commonly known as the "funny bone" because striking the elbow on a hard surface stimulates the ulnar nerve and produces a tingling sensation. The Forearm The forearm is the region between the elbow and the wrist. It is formed by the radius on the lateral side and the ulna on the medial side when the forearm is viewed in the anatomical position. The ulna is longer than the radius and connected more firmly to the humerus. The radius, however, contributes more to the movement of the wrist and hand than the ulna. When the hand is turned over so that the palm is facing downwards, the radius crosses over the ulna. The top of each bone connects to the humerus of the arm and the bottom of each connects to the bones of the hand.

The Hand The hand consists of three parts (the wrist, palm, and five fingers) and 27 bones. The wrist, or carpus, consists of 8 small bones called the carpal bones that are tightly bound by ligaments. These bone are arranged in two rows of four bones each. The top row (the row closest to the forearm) from the lateral (thumb) side to the medial side contains the scaphoid, lunate, triquetral, and pisiform bones. The second row from lateral to medial contains the trapezium, trapezoid, capitate, and hamate. The scaphoid and lunate connect to the bottom of the radius. The palm or metacarpus consists of five metacarpal bones, one aligned with each of the fingers. The metacarpal bones are not named but are numbered I to V starting with the thumb. The bases of the metacarpal bones are connected to the wrist bones and the heads are connected to the bones of the fingers. The heads of the metacarpals form the knuckles of a clenched fist. The fingers are made up of 14 bones called phalanges. A single finger bone is called a phalanx. The phalanges are arranged in three rows. The first row (the closest to the

metacarpals) is called the proximal row, the second row is the middle row, and the farthest row is called the distal row. Each finger has a proximal phalanx, a middle phalanx, and a distal phalanx, except the thumb (also called the pollex) which does not have a middle phalanx. The digits are also numbered I to V starting from the thumb.

The lower extremity is composed of the bones of the thigh, leg, foot, and the patella (commonly known as the kneecap).

The Thigh The thigh is the region between the hip and the knee and is composed of a single bone called the femur or thighbone. The femur is the longest, largest, and strongest bone in the body. The Leg The leg is technically only the region from the knee to the ankle. It is formed by the fibula on side away from the body (lateral side) and the tibia, also called the shin bone, on the side nearest the body (medial side). The tibia connects to the

femur to form the knee joint and with the talus, a foot bone, to allow the ankle to flex and extend. The tibia is larger than the fibula because it bears most of the weight, while the fibula serves as an area for muscle attachment.

The foot's two arches are formed by the structure and arrangement of the bones and are maintained by tendons and ligaments. The arches give when weight is placed on the foot and spring back when the weight is lifted off of the foot. The arches may fall due to a weakening of the ligaments and tendons in the foot.

The Foot The foot, or pes, contains the 26 bones of the ankle, instep, and the five toes. The ankle, or tarsus, is composed of the 7 tarsal bones which correspond to the carpals in the wrist. The largest tarsal bone is called the calcaneus or heel bone. The talus rests on top of the calcaneus and is connected to the tibia. Directly in front of the talus is the navicular bone. The remaining bones from medial to lateral are the medial, intermediate, the lateral cuneiform bones, and the cuboid bone. The metatarsal and phalanges bones of the foot are similar in number and position to the metacarpal and phalanges bones of the hand. The five metatarsal bones are numbered I to V starting on the medial side with the big toe. The first metatarsal bone is larger than the others because it plays a major role in supporting the body's weight. The 14 phalanges of the foot, as with the hand, are arranged in a proximal row, a middle row, and a distal row, with the big toe, or hallux, having only a proximal and distal phalanx.

The Patella The patella or kneecap is a large, triangular sesamoid bone between the femur and the tibia. It is formed in response to the strain in the tendon that forms the knee. The patella protects the knee joint and strengthens the tendon that forms the knee. The bones of the lower extremities are the heaviest, largest, and strongest bones in the body because they must bear the entire weight of the body when a person is standing in the upright position.

The Shoulder Girdle, also called the Pectoral Girdle, is composed of four bones: two clavicles and two scapulae .

The clavicle, commonly called the collarbone, is a slender S-shaped bone that connects the upper arm to the trunk of the body and holds the shoulder joint away from the body to allow for greater

freedom of movement. One end of the clavicle is connected to the sternum and one end is connected to the scapula. The scapula is a large, triangular, flat bone on the back side of the rib cage commonly called the shoulder blade. It overlays the second through seventh rib and serves as an attachment for several muscles. It has a shallow depression called the glenoid cavity that the head of the humerus (upper arm bone) fits into. Usually, a "girdle" refers to something that encircles or is a complete ring. However, the shoulder girdle is an incomplete ring. In the front, the clavicles are separated by the sternum. In the back, there is a gap between the two scapulae. The primary function of the pectoral girdle is to provide an attachment point for the numerous muscles that allow the shoulder and elbow joints to move. It also provides the connection between the upper extremities (the arms) and the axial skeleton.

The Pelvic Girdle

The Pelvic Girdle, also called the hip girdle, is composed to two coxal (hip) bones. The coxal bones are also called the ossa coxae or innominate bones. During childhood, each coxal bone consists of three separate parts: the ilium (denoted in purple above), the ischium (denoted in red above), and the pubis (denoted in blue above). In an adult, these three bones are firmly fused into a single bone. In the picture above, the coxal bone on the left side has been divided into its component pieces while the right side has been preserved. In the back, these two bones meet on either side of the sacrum. In the front, they are connected by a muscle called the pubic symphysis (denoted in green above). The pelvic girdle serves several important functions in the body. It supports the weight of the body from the vertebral column. It also protects and supports the lower organs, including the urinary bladder, the reproductive organs, and the developing fetus in a pregnant woman. The pelvic girdle differs between men and woman. In a man, the pelvis is more massive and the iliac crests are closer together. In a woman, the pelvis is more delicate and the iliac crests are farther apart. These differences reflect the woman's role in pregnancy and delivery of children. When a child is born, it must pass through its mother's pelvis. If the opening is too small, a cesarean section may be necessary.

Other Bone Diseases

Bone spurs, also known as osteophytes, are bony projections that form along joints. Bone spurs form due to the increase in a damaged joint's surface area. This is most commonly from the onset of arthritis. Bone spurs usually limit joint movement and typically cause pain. Bone spurs form naturally on the back of spine as a person ages and are a sign of degeneration in the spine. In this case the spurs are not the source of back pains, but instead are the common symptom of a deeper problem. However, bone spurs on the spine can impinge on nerves, which leave the spine for other parts of the body. This impingement can cause pain in both upper and lower limbs and a numbness or tingling sensations in the hands and feet due to the nerves supplying sensation to their dermatomes. Cause Osteophyte formation has been classically related to any sequential and consequential changes in bone formation due to aging, degeneration, mechanical instability, and disease. Often osteophytes form in osteoarthritic joints due to damage and wear from inflammation. Calcification and new bone formation can also occur in response to mechanical damage in joints, or

at the attachment points for ligaments and tendons. Symptoms: • • • • • • • •

Back ache Mild pain in the neck Pain in the shoulders in case the bone spur occurs in the cervical spine Headache Pain in thighs when bone spur takes place in the lumbar spine Numbness General weakness Pain in arms and legs

Diagnostic Electroconductive tests are commonly performed to document the degree and severity of spinal nerve injury. The EMG and nerve conduction test (EMG/NCV) tests will exclude peripheral nerve compression such as carpal tunnel syndrome. Radiographs begin with an x-ray of the spine to determine the extent of arthritic changes and bone spur formation. With these films the physician may determine if destructive changes are present or further radiographic images are indicated. Computerized tomography (CT scans) with myelography and/or MRI scans can provide details about change in the spinal architecture and the degree of nervous system compression. With these films the clinician will correlate clinical symptoms with radiographic findings and recommend the corrective course of action, often seeking the consultation of the spine surgeon.

on where your bone spurs are located and your particular situation.

Fibrous dysplasia is a disease that causes bone thinning and growths or lesions in one or more bones of the human body.

Radiograph of bone spur

Treatments There's no specific treatment for bone spurs. If your bone spurs don't cause you any pain or if they don't limit any range of motion in your joints, then you likely won't need treatment. If you need treatment, it's typically directed at the underlying problem to prevent further joint damage. Medications If your bone spurs are causing pain, your doctor may recommend nonsteroidal antiinflammatory drugs (NSAIDs) to ease the pain. Surgery Bone spurs that limit your range of motion or cause other problems that limit your ability to go about your day may require surgery. What surgical options you have will depend

Causes Fibrous dysplasia is very rare; not much is known about it, and there is no known cure. However, it is known that it is caused by a genetic mutation that occurs sometime during fetal development, and is not hereditary. There are two types of fibrous dysplasia: 1. Monostotic (Involving a single bone), and 2. Polystotic (Involving many bones). The most severe form of polystotic fibrous dysplasia is known as Albright Syndrome. Symptoms Fibrous dysplasia can affect any bone in your body. Most people with the disorder have only one affected bone — a form called monostotic fibrous dysplasia — and develop no signs or symptoms. When the condition affects more than one bone, it's known as polyostotic fibrous dysplasia. Bones most commonly affected are: • • • • • • •

Thighbone (femur) Shinbone (tibia) Pelvic bones Ribs Skull Facial bones Upper arm bone (humerus)

Fibrous dysplasia may cause few or no signs and symptoms, particularly if the condition is mild. Signs and symptoms may develop during childhood,

adolescence or adulthood. If you have the polyostotic form, you're more likely to develop signs and symptoms, usually by age 10. More severe fibrous dysplasia may cause: • • • •

Bone pain Difficulty walking Bone deformities Fractures

Diagnosis If you have monostotic fibrous dysplasia, you may not know it until it's discovered incidentally on an X-ray for another condition. If you have signs and symptoms, your doctor will perform a physical examination and order X-rays of the affected bones. On Xray, fibrous dysplasia appears as an abnormal section of bone (lesion) that has the hazy appearance of ground glass.

•

•

take up the tracers and emit radiation that's captured by a special camera, which produces a picture of your skeleton. Your doctor may order a bone scan to determine whether your fibrous dysplasia is monostotic or polyostotic. Bone biopsy. Surgically removing a sample of affected bone for examination under a microscope is necessary only if your doctor suspects cancer. During a biopsy, a surgeon removes a small piece of your affected bone for analysis in a laboratory.

In some cases, your doctor may order more tests to confirm diagnosis or to determine the extent of the disorder. They include: •

•

Imaging tests. Computerized tomography (CT) or magnetic resonance imaging (MRI) scans may be used to determine how extensively your bones are affected. Bone scan. This test uses radioactive tracers, which are injected into your body. Your bones

Fibrous Dysplasia-MRI.

Treatment If you have mild fibrous dysplasia that's discovered incidentally and you have no signs or symptoms, your risk of developing deformity or fracturing your bone is low. Your doctor can monitor your condition with follow-up Xrays every six months. If there's no progression, you don't need treatment. If you develop signs and symptoms, treatment may include medications or surgery.

generally well tolerated, but may irritate your gastrointestinal tract. Some bisphosphonates aren't available as oral medications, and you must receive them through a vein (intravenously). The drug tends to work faster when you receive it through a vein than if you take it orally, and intravenous administration provides an option when you can't tolerate or otherwise aren't a candidate for oral bisphosphonates. You can't take bisphosphonates if you have serious kidney disease or low blood calcium levels. Surgery

Medications Medications called bisphosphonates, including pamidronate (Aredia) and alendronate (Fosamax), are used to inhibit bone breakdown, preserve bone mass and even increase bone density in your spine and hip, reducing the risk of fractures. Doctors use these medications primarily for adults to treat osteoporosis and increase bone density, but bisphosphonates may also reduce bone pain associated with fibrous dysplasia, and, in some cases, improve bone formation. Little is known about the use of bisphosphonates for children and adolescents, but some studies indicate they may help relieve pain in children and adolescents with severe fibrous dysplasia. Oral bisphosphonates are

Your doctor may recommend surgery in order to: • • • •

Correct a deformity Fix a fracture Remove an affected area of bone (lesion) that's causing you difficulty Relieve pressure on a nerve, particularly if the lesion is in your skull or face

Surgery may involve removing the bone lesion and replacing it with bone from another part of your body. Your surgeon may insert metal plates, rods or screws to stabilize the bone and the graft. Risks include infection, blood clots and bleeding. In addition, a bone graft may not last.

Osteopenia is a condition where bone mineral density is lower than normal. It is considered by many doctors to be a precursor to osteoporosis. However, not every person diagnosed with osteopenia will develop osteoporosis. More specifically, osteopenia is defined as a bone mineral density T score between -1.0 and -2.5. Causes Like osteoporosis, osteopenia occurs more frequently in postmenopausal women as a result of the loss of estrogen. It can also be exacerbated by lifestyle factors such as lack of exercise, excess consumption of alcohol, smoking or prolonged use of glucocorticoid medications such as those prescribed for asthma. The condition can occur in young women who are athletes. It is associated with female athlete triad syndrome as one of the three components, the other two being amenorrhea and disordered eating. Female athletes tend to have lower body weight, lower fat percentage, and higher incidence of asthma than their less active peers. The low estrogen levels (stored in body fat) and / or use of corticosteroids to treat asthma can significantly weaken bone over long periods of time. Distance runners in particular are also discouraged from consuming milk products when

training, which would result in lower calcium absorption than other groups. Symptoms There are no symptoms associated with the early stages of osteopenia. As such, osteopenia is a silent risk factor for fractures. Symptoms occurring during later stages include fractures of the vertebrae, wrists or hips (usually the first indication); low back pain; neck pain; bone pain and tenderness; loss of height over time; and a stooped posture. Diagnosis The pharmaceutical company Merck, which sells the anti-bone-loss drug Fosamax, estimated in 2003, from its own market research, that about 8 million women had been found to have osteopenia and about a third of them were taking an osteoporosis drug. Scans of bones anywhere in the body can be done with X-rays, known as Dexa (Dual energy X-ray absorptiometry). Scans can also be done with portable scanners using ultrasound, and portable X-ray machines can measure density in the heel. A study paid for by Merck found that the extent to which osteopenia was diagnosed varied from 28 to 45 percent, depending on the type of machine.

radiograph of knees shows periarticular osteopenia, prominent tibial spines, and interosseous cysts (arrows)

Paget's disease, otherwise known as osteitis deformans, is a chronic disorder that typically results in enlarged and deformed bones. It is named after Sir James Paget, the British surgeon who first described this disease. The excessive breakdown and formation of bone tissue that occurs with Paget's disease can cause bone to weaken, resulting in bone pain, arthritis, deformities, and fractures. Cause Although the exact cause of Paget's disease is unknown, it appears to run in families. Up to 30 % of people with the disease have other family members who also have it. Some researches believe that a virus may be involved, but a specific virus has not been identified. Whatever the cause, Paget's disease results in abnormal bone remodeling (the normal process of bone breakdown and rebuilding). In Paget's disease, when bone is broken down, it is replaced with soft bone. The bone is weak and can bend easily. As bones rebuild, they can also become larger than before. Symptoms Many patients do not know they have Paget's disease because they have a mild case with no symptoms. Sometimes, symptoms may be confused with those of arthritis or other disorders. In other

cases, the diagnosis is made only after complications have developed. Symptoms can include: •

• • • • • • • • •

Bone pain is the most common symptom. Bone pain can occur in any bone affected by Paget's disease. It often localizes to areas adjacent to the joints. Headaches and hearing loss may occur when Paget's disease affects the skull. Pressure on nerves may occur when Paget's disease affects the skull or spine. Somnolence (drowsiness) due to vascular steal syndrome of the skull. Paralysis due to vascular steal syndrome of the vertebrae. Increased head size, bowing of limb, or curvature of spine may occur in advanced cases. Hip pain may occur when Paget's disease affects the pelvis or thighbone. Damage to joint cartilage may lead to arthritis. Teeth may spread intraorally. Chalkstick fractures.

Diagnosis Paget's disease may be diagnosed using one or more of the following tests: • •

Pagetic bone has a characteristic appearance on x-rays. A skeletal survey is therefore indicated. An elevated level of alkaline phosphatase in the blood in combination with normal calcium, phosphate, and aminotransferase levels in an elderly patient are suggestive of Paget's disease.

•

Bone scans are useful in determining the extent and activity of the condition. If a bone scan suggests Paget's disease, the affected bone(s) should be xrayed to confirm the diagnosis.

and throat disorders) may be called upon to evaluate specialized symptoms. Drug therapy The goal of treatment is to relieve bone pain and prevent the progression of the disease. The U.S. Food and Drug Administration has approved the following treatments for Paget's disease: Bisphosphonates

Radiograph of Tibia w/ Paget’s Disease.

Types of physicians The following types of medical specialists are generally knowledgeable about treating Paget's disease. •

•

•

Endocrinologists -Internists who specialize in hormonal and metabolic disorders. Rheumatologists -Internists who specialize in joint and muscle disorders. Specialists -- Orthopedic surgeons, neurologists, and otolaryngologists (physicians who specialize in ear, nose,

Five bisphosphonates are currently available. In general, the most commonly prescribed are the three most potent bisphosphonates: Actonel, Fosamax and Aredia. Didronel and Skelid may be appropriate therapies for selected patients but are less commonly used. As a rule, bisphosphonate tablets should be taken with 6–8 oz of tap water (not from a source with high mineral content) on an empty stomach. None of these drugs should be used by people with severe kidney disease. Didronel (etidronate disodium) -- Tablet; approved regimen is 200–400 mg once daily for 6 months; the higher dose (400 mg) is more commonly used; no food, beverages, or medications for 2 hours before and after taking; course should not exceed 6 months, but repeat courses can be given after rest periods, preferably of 3–6 months duration. Aredia (pamidronate disodium) -Intravenous; approved regimen 30 mg infusion over 4 hours on 3 consecutive days; more commonly used regimen 60 mg over 2–4 hours for 2 or more consecutive or non-consecutive days. Fosamax (alendronate sodium) -- Tablet; 40 mg once daily for 6 months; patients should wait at least 30 minutes after

taking before eating any food, drinking anything other than tap water, taking any medication, or lying down (patient may sit). Skelid (tiludronate disodium) -- Tablet; 400 mg (two 200 mg tablets) once daily for 3 months; may be taken any time of day, as long as there is a period of 2 hours before and after resuming food, beverages, and medications. Actonel (risedronate sodium) -Tablet; 30 mg once daily for 2 months; patients should wait at least 30 minutes after taking before eating any food, drinking anything other than tap water, taking any medication, or lying down (patient may sit). Calcitonin Miacalcin is administered by injection; 50 to 100 units daily or 3 times per week for 6-18 months. Repeat courses can be given after brief rest periods. Miacalcin may be appropriate for certain patients but is seldom used. The nasal spray form of this drug is not approved for the treatment of Paget's disease.

Surgery Medical therapy prior to surgery helps to decrease bleeding and other complications. Patients who are having surgery should discuss pre-treatment with their physician. There are generally three major complications of Paget's disease for which surgery may be recommended. • •

•

Fractures -- Surgery may allow fractures to heal in better position. Severe degenerative arthritis -- If disability is severe and medication and physical therapy are no longer helpful, joint replacement of the hips and knees may be considered. Bone deformity -- Cutting and realignment of Pagetic bone (osteotomy) may help painful weight bearing joints, especially the knees.

Complications resulting from enlargement of the skull or spine may injure the nervous system. However, most neurologic symptoms, even those that are moderately severe, can be treated with medication and do not require neurosurgery. Diet and Exercise In general, patients with Paget's disease should receive 1000-1500 mg of calcium, adequate sunshine, and at least 400 units of vitamin D daily. This is especially important in patients being treated with bisphosphonates. Patients with a history of kidney stones should discuss calcium and vitamin D intake with their physician. Exercise is very important in maintaining skeletal health, avoiding weight gain, and maintaining joint mobility. Since undue stress on affected bones should be avoided, patients should discuss any

exercise program with their physician before beginning.

Renal osteodystrophy is a bone pathology, characterized by defective mineralization, that results from kidney disease. Renal osteodystrophy comes in two different forms, high bone turnover and low bone turnover. Symptoms Renal osteodystrophy may exhibit no symptoms; if it does show symptoms, they include: • • • •

Bone pain Joint pain Bone deformation Bone fracture

Diagnosis Renal osteodystrophy is usually diagnosed after treatment for end-stage renal disease begins. Blood tests will indicate decreased calcium and calcitriol and increased phosphate and parathyroid hormone. X-rays will also show bone features of renal osteodystropy (chondrocalcinosis at the knees and pubic symphysis, osteopenia and bone fractures) but may be difficult to differentiate from other conditions.

Radiograph of Fingers w/ osteodystrophy

Treatment Treatment for renal osteodystrophy includes: • • •

• • •

calcium and vitamin D supplementation restrictionof dietary phosphate phosphate binders such as calcium carbonate, calcium acetate, sevelamer hydrochloride, or lanthanum carbonate cinacalcet renal transplantation hemodialysis five times a week is thought to be of benefit.

Giant cell tumor of the bone (also called giant cell myeloma or osteoclastoma) is a relatively uncommon tumor. It is characterized by the presence of multinucleated giant cells (osteoclast-like cells). These tumors are generally benign. In most patients, the tumors are slow to develop, but may recur locally in as many as 50% of cases. Metastasis to the lungs may occur.

problems. Always consult your physician for a diagnosis. Diagnosed In addition to a complete medical history and physical examination, diagnostic procedures for giant cell tumors may include the following: •

x-rays - a diagnostic test which uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film.

Cause While the exact cause of giant cell tumors remains unknown, in some cases, they have been linked to Paget's disease. Paget's disease of the bone is a chronic bone disorder in which bones become enlarged and deformed.

•

radionuclide bone scans - a nuclear imaging method to evaluate any degenerative and/or arthritic changes in the joints; to detect bone diseases and tumors; to determine the cause of bone pain or inflammation. This test is to rule out any infection or fractures.

Symptoms The following are the most common symptoms of a giant cell tumor. However, each individual may experience symptoms differently. Symptoms may include: • pain at the adjacent joint • a visible mass • swelling • bone fracture • limited movement in the adjacent joint • fluid accumulation in the joint adjacent to the affected bone The symptoms of a giant cell tumor may resemble other medical conditions or

•

biopsy - a procedure in which tissue samples are removed (with a needle or during surgery) from the body for examination under a microscope; to determine if cancer or other abnormal cells are present.

X-ray of a giant cell bone tumor in the head of the 4th metacarpal of the left hand.

Osteitis fibrosa cystica, also known as Von Recklinghausen's disease of bone, is characterized by increased osteoclastic resorption of calcified bone with replacement by fibrous tissue. It may be caused by Secondary hyperparathyroidism or other causes of the rapid mobilization of mineral salts. The bone problems associated with the disorder osteitis fibrosa are usually reversible with surgery, except in the case of fluid filled cysts, which require non-surgical attention. Causes Anything that causes hyperparathyroidism can lead to Osteitis fibrosa cystica. It is particuarly prevalent among patients with end stage renal disease due to the decreased synthesis of Vitamin D from the kidneys. Symptoms Osteitis fibrosa cystica can lead to bone pain or tenderness, pathological fractures in the arms, legs, or spine, and deformities (bowing of the bones). Being a precursor to the disorder, hyperparathyroidism itself may cause kidney stones, nausea, constipation, fatigue and weakness. Blood tests show a high level of serum calcium and alkaline phosphatase, and low serum

phosphorus. X-rays may indicate thin bones, fractures, bowing, and cysts. The cysts may be lined by osteoclasts, filled with fibrous stroma and sometimes blood ("brown tumors"). The skull may look like "ground glass" or "salt and pepper." The outer part of bones may be eroded; the most sensitive area to check is the fingers. Teeth X-rays may also be abnormal. Diagnosis Blood tests show a high level of calcium, parathyroid hormone, and alkaline phosphatase (a bone chemical). Phosphorus may be low.X-rays may show thin bones, fractures, bowing, and cysts. Teeth x-rays may also be abnormal.A bone x-ray may be done. People with hyperparathyroidism are more likely to have osteopenia (thin bones) or osteoporosis (very thin bones) than to have full-blown osteitis fibrosa.

This is a cross section from a femur of a patient who suffered from hyperparathyroidism.

Treatment The main treatment for hyperparathyroidism is surgery to remove the abnormal parathyroid gland(s). Newer techniques use radioactive tracers and rapid parathyroid hormone blood tests to make the surgery quicker and easier. If surgery is not possible, drugs can sometimes be used to lower calcium levels.

Osteochondritis dissecans (typically abbreviated to OCD) is a form of osteochondritis. It is commonly accepted that trauma, avascular necrosis and other causative factors affecting the subchondral (below cartilage) bone can lead to the loss of support for adjacent cartilaginous structures and precede the separation of an articular fragment from the underlying bone and formation loose bodies. Cause Although the etiology is not certain, possible causative factors include repetitive trauma, ischemia, hereditary and endocrine factors, avascular necrosis, rapid growth, deficiencies and imbalances in the ratio of calcium to phosphorus, and anomalies of ossification. Trauma, rather than avascular necrosis, is thought to be the factor which localizes and determines the development of osteochondritis dissecans in

juveniles. In the adult group of cases trauma is thought to be the main or perhaps the sole factor in determining the onset of osteochondritis dissecans. The trauma may be endogenous and/or exogenous. Interestingly, the incidence of overuse injuries in young athletes is on the rise and accounts for a significant number of visits to the primary care office; this reinforces the theory that OCD may be associated with increased participation in sports and subsequent trauma. Symptoms The symptoms of osteochondritis dissecans are pain and swelling of the affected joint, catching and locking on movement and a restriction in the range of movement. These symptoms characterize many knee conditions and may have a broad range of other causes, making OCD relatively hard to clinically diagnose. Diagnosis To determine whether pains are osteochondritis dissecans, an MRI, CT scan or X-ray can be performed to show necrosis of subchondral bone and/or formation of loose fragments. In specific cases, if caught early enough, a harmless dye will be injected into the blood stream to show where calcium will accumulate. Physical examination A special test known as the "Wilson sign" has been described to locate OCD lesions of the femoral condyle. The test is performed by slowly extending the knee from 90 degrees while maintaining internal rotation. Pain reported at 30 degrees of flexion and relief with tibial external rotation is a positive result.

Non-surgical treatment

MRI of the elbow showing edema in the capitellum with an osteochondritis dissecans lesion.

Treatment Treatment options include modified activity with or without weight-bearing; immobilization; cryotherapy; anti-inflammatories; drilling of subchondral bone to improve vascularity; microfracture; reattachment and removal of loose bodies and autologous osteochondral plugs (OATS). The principles of treatment are to enhance the healing potential of subchondral bone, fix unstable fragments while maintaining joint congruity, and to replace the damaged bone and cartilage with implant tissues or cells that can replace bone and grow cartilage. However, the capacity of articular cartilage for repair is limited. Partial-thickness defects in the articular cartilage do not heal spontaneously. "Injuries of the articular cartilage that do not penetrate the subchondral bone" do not heal and usually progress to the "degeneration of the articular surface." As a result, surgery is often required in even moderate cases (stage II, III) of OCD.

Candidates for non-operative treatment include those who are skeletally immature with an intact lesion and no loose bodies. Non-operative management may include activity modification, protected weight bearing (partial or non-weight bearing), and immobilization. The goal of nonoperative intervention is to promote healing in the subchondral bone and potentially prevent chondral collapse, subsequent fracture, and crater formation. Surgical treatment The choice of surgical verse non-surgical treatments for osteochondritis dissecans is still controversial. Consequently, the type and extent of surgery necessary varies based on patient age, severity of the lesion, and personal bias of the treating surgeon—entailing an exhaustive list of suggested treatments. Thus, a variety of surgical options exist for the treatment of persistently symptomatic, intact, partially detached, and completely detached OCD lesions.