Overview - The skeletal system

Topic Introduction
Welcome to Module 4! This is a huge topic, so we are going to tackle it slightly
differently. As we don’t want you to learn every bone in the body – you can if you
want – but this isn’t Anatomy 101, we will highlight some key points from the
relevant text book chapters rather than summarise them like previous modules.
Remember, this subject is not only anatomy and physiology, but nursing
assessment also, so as you are going through these modules, try and reflect on how
what you are learning applies to nursing practice and assessment. Your readings in
your Skills in Clinical Nursing text helps with this.

Learning outcomes

Bones and skeletal tissues

● Describe the functional properties of the three types of cartilage tissue
● Locate the major cartilages of the adult skeleton
● Describe the functions of the skeleton and of bone tissue
● Name the major regions of the skeleton and describe their relative functions
● Compare and contrast the four bone classes and provide examples of each
class
● Describe the gross anatomy of a typical flat and long bone. Indicate the
locations and functions of red and yellow marrow, articular cartilage,
periosteum, and endosteum
● Discuss the chemical composition of bone and the advantages conferred by
its inorganic and organic components
● Compare the locations and remodeling functions of the osteoblasts,
osteocytes, and osteoclasts
● Explain how hormones and physical stress regulate bone remodeling
The skeleton
● Main bones of the appendicular skeleton
● Describe the structure of the vertebral column, list its components, and
describe its curvatures
● Indicate a common function of the spinal curvatures and the intervertebral
discs
● Name and describe the bones of the thoracic cage
● Differentiate true from false ribs

Joints
● Define joint or articulation
● Classify joints by structure and by function
● Describe the structure of Fibrous joints – name and give an example of each
of the three common types
● Describe the structure of Cartilaginous joints – name and give an example of
each of the two common types
● Describe the structural characteristics of Synovial joints - name and provide
an example of the six types
● List three natural factors that stabilise synovial joints
● Name and describe the common body movements Compare the structures
and functions of bursae and tendon sheaths
● Compare the structures and functions of bursae and tendon sheaths
● Name the most common joint injuries and discus the symptoms and problems
associated with each
● Compare and contrast the common types of arthritis

4.1.1 Cartilage
The skeletal cartilage found in the adult human skeleton is found mainly in regions
where flexible skeletal tissue is needed.

Basic structure, types and locations

Skeletal cartilage is made up of a variety of cartilage tissue sculpted to fit its body
location and function.

● It consists primarily of water

● very resilient
● contains no nerves or blood vessels
● surrounded by a layer of dense irregular connective tissue called
perichondrium
● acts as a reinforcement to resist outward expansion when the cartilage is
compressed
● contains blood vessels that nourish cartilage cells
● Three types:
All have the same basic components
1) Lacunae enclosing chondrocyte cells
2) An extracellular matrix containing jelly-like ground substance,
fibres and lacunae
1. Hyaline: provides support with flexibility and resistance
1) Most abundant
2) Articular: cover the ends of most bones at moveable joints
3) Costal: connect the ribs to the sternum
4) Respiratory: form the skeleton of the larynx and reinforce other
respiratory passageways
5) Nasal: support the external nose

2. Elastic: resemble hyaline but contain stretcher elastic fibres so are

better able to stand up to repeated bending.
1) Only found in two locations in the body
2) The external ear
3) The epiglottis

3. Fibrocartilage: these are highly compressible with great tensile

strength
1) Occur in sites that are subjected to both pressure and stretch
2) Menisci of the knee
3) Discs between spine vertebrae
4.1.2 The skeleton
There are seven important functions that bones perform:

● Support: provides a framework that supports the body and cradles the
organs
● Protection
● Anchorage: skeletal muscles, which attach to bones by tendons, use bones
as levers to move the body and its parts. The design of joints (which we will
discuss soon) determines the types of movement possible
● Mineral storage: bone is a reservoir for minerals – most importantly calcium
and phosphate
● Blood cell formation (haematopoiesis): occurs in the red marrow of certain
bones
● Triglyceride (fat) storage: stored as yellow marrow in the cavities of long
bones
● Hormone production: bones produce osteocalcin which helps to regulate
insulin secretion, glucose homeostasis, and energy expenditure
4.1.3 Bone classification
There are 206 named bones in the human skeleton, as we said earlier – you don’t
need to know the names of them all, but be familiar with them, and know what we
teach you. They are divided into two groups, axial and appendicular.

● Axial skeleton: forms the long axis of the body

1. Includes bones of the skull, vertebral column, and rib cage
2. Project
3. Support
4. Carry other body parts
● Appendicular skeleton
1. Includes bones of upper and lower limbs and the shoulder and hip
bones (girdles)
2. Help us move
3. Help us manipulate our environment
These bones come in many shapes and sizes and are classified by their shape into
the following four classifications:

● Long bones
1. Longer than they are wide

● Short bones
1. Roughly cubed shaped
2. Sesamoid bones are special short bones that form in a tendon and can
act to alter the direction of pill of a tendon or reduce friction and modify
pressure on tendons to reduce abrasion or tearing

● Flat bones
1. Thin, flattened, usually a bit curved

● Irregular bones
1. Complicated shaped that don’t fit any of the above classifications
4.1.4 Gross bone structure
Due to the fact bones contain different types of tissue, they are considered organs.
They contain:

● Bone (osseous) tissue

● Nervous tissue in their nerves
● Cartilage in their articular cartilages
● Dense connective tissue covering their external surfaces
● Muscle and epithelial tissues in their blood vessels

There are three levels we can examine:

● Gross
● Microscopic
● Chemical

Gross anatomy
Compact and spongy bone
● Compact bone: the dense outer layer
● Spongy bone (trabecular bone): a honeycomb of small flat pieces called
trabeculae
1. In living bones, the open spaces between the trabeculae are filled with
red or yellow bone marrow

Structure of short, flat and irregular bones

● All share a simple pattern:
● Thin plates of spongy bone covered by compact bone
● Compact bone is covered by connective tissue membranes on both sides:
1. Periosteum on the outside
2. Endosteum on the inside
● Contain bone marrow but no defined well-defined marrow cavity
● Hyaline cartilage covers their surfaces where they form movable joints with
their neighbours
Structure of long bone
Most long bones have the same general structure:

● Diaphysis (shaft): forms the long axis

1. Constructed of a relatively thick collar of compact bone that surrounds
a central cavity called the medullary cavity or marrow cavity, that
contains yellow marrow
● Epiphysis: forms the bone end (plural is epiphyses)
1. An outer shell of compact bone
 2. Interior contains spongy bone
3. A thin layer of articular cartilage covers the joint surface
● Membranes: Two membranes
1. Periosteum: white double-layered membrane covering external surface
except for joint surfaces
1) outer layer – fibrous: dense irregular connective tissue
2) inner layer – osteogenic: contains:
➢ osteoprogenitor cells – primitive stem cells
➢ osteoclasts – bone destroying cells
➢ osteoblasts – bone forming cells
3) richly supplied with nerve fibres and blood vessels
4) perforating fibres – bundles of collagen that extend into the bone
matrix – secure the periosteum to the underlying bone
5) provides anchoring points for tendons and ligaments =
perforating fibres are exceptionally dense at these points
2. Endosteum: delicate connective tissue membrane that covers the
internal bone surfaces
1) Contains the same cells as the inner layer of the periosteum
● Blood vessels and nerves: bones are well vascularised
1. Nutrient foramen: a hole in the wall of the diaphysis through which
nerves and the main blood vessels the nutrient artery and nutrient vein
enter the bone

Haematopoietic tissue (Red marrow) in bones

Haematopoietic (blood forming tissue) in adults is found only in a few areas as most
has been replaced by yellow marrow. It is found in:

● The flat bones of the skull, sternum, ribs, clavicles, scapulae, hip bones and
vertebrae
● The heads of the femur and humerus

From a nursing and medical perspective, the red marrow found in flat bones and
irregular bones is much more active in haematopoiesis than that in long bones. So,
when a bone marrow sample is required, that is why it is often taken from the hip.
Microscopic anatomy

Cells of bone tissue

● Osteoprogenitor cells
1. Mitotically active stem cells found in the periosteum and endosteum
2. When stimulated they differentiate into osteoblasts
● Osteoblasts
1. Bone forming cells that secrete the bone matrix
2. Actively mitotic
3. Play a role in matrix calcification
 4. When become completely surrounded by matrix being secreted, they
become osteocytes
● Osteocytes
1. Mature bone cells that occupy lacunae that conform to their shape
2. Monitor and maintain the bone matrix
3. Act as stress or strain sensors
4. Respond to mechanical stimuli
5. Can trigger bone remodelling to maintain calcium homeostasis
● Bone lining cells
1. Flat cells found on bone surfaces where bone remodelling is not going
on
2. Thought to help maintain the matrix
● Osteoclasts
1. Giant multinucleate cells found at sites of bone resorption
2. Deep plasma membrane infoldings enzymatically degrade bone and
seal off the areas from the surrounding matrix
Chemical composition of bone

Bone contains both organic and inorganic substances, making it extremely strong
and durable.

● Organic components: allow it to resist tension

1. Soft
2. Include bone cells and osteoid – the organic part of the matrix
● Inorganic components: allow it to resist compression
1. Hard
2. Composed of mineral salts – mainly calcium and phosphate

4.1.5 Bone remodeling

Every year, remodeling replaces about 5-10% of the human skeleton, and the entire
skeleton is replaced about every 10 years. This is essential because the longer bone
remains in place, more calcium crystallises, and the more brittle bone becomes.
Bone remodeling consists of bone resorption and deposits and is coordinated by
cohorts of osteoblasts and osteoclasts which respond to signals from hormones and
stress sensing osteocytes. This process does not occur uniformly.

Control of remodeling
Remodelling is a continual process regulated by two loops that serve different
purposes:

● Maintaining Calcium homeostasis

1. Hormonal negative feedback loop involving parathyroid hormone
determines whether and when remodelling occurs
● Keeping bone strong
1. Mechanical and gravitational forces acting on a bone drive remodelling
where it is required to strengthen that bone

Hormonal controls
Maintaining extracellular fluid calcium levels within homeostatic levels is absolutely
critical for maintaining the resting membrane potential of all cells

Response to mechanical stress

Wolff’s law holds that a bone grows or remodels on response to the demands placed
on it

● A bones anatomy reflects the common stresses it encounters

● Handedness results in the bones of one upper limb being thicker than those
of the less used limb
● Curved bones are thickest where they are most likely to buckle
● The trabeculae of spongy bone form trusses, or struts, along lines of
compression
● Large, bony projections occur where heavy, active muscles attach

4.1.6 Fractures
Fracture classification

Fractures can be classified by:

● Position of bone ends after the fracture:

1. Nondisplaced: bone ends retain normal position
2. Displaced: bone ends are out of alignment
● Completeness of break:
1. Complete: bone is broken through
2. Incomplete: bone not broken through
● Whether bone end penetrate skin:
1. Penetrate: open (compound) fracture
2. Don’t penetrate: closed (simple) fracture

4.2 PART 2: The skeleton

As we identified earlier, we don’t want you to name every bone by heart. However,
we expect you know the general layout. As you progress you will learn more and
more and if you specialise in orthopaedics, surgical or other specialist areas you will
come to know certain areas of the body very well and forget others. So, having said
that, knowing the bones of the axial and apical skeleton is a good solid foundation to
have.
The following tables have been included identifying these bones, so you know what
you need to know.

The axial and appendicular skeletons

The vertebral column

● The vertebral or spinal column consists of 26 bones connected in such a way
that a flexible, curved structure results
● extends from the skull to the pelvis where it transmits the weight of the trunk
to the lower limbs
● surrounds and protects the spinal cord
● provides attachment points for the ribs, muscles of the back and neck
The thoracic cage
The thoracic cage + Ribs
There are twelve pairs of ribs in the thoracic cage. All attach posteriorly to the
thoracic vertebrae.

● True (vertebrosternal) ribs: the superior seven rib pairs that attach directly to
the sternum by individual costal cartilages

● False (vertebrocondral) ribs: the inferior five rib pairs that attach to the
sternum either indirectly or not at all. Rib pairs 11 and 12 are called
vertebral/floating ribs as they have no anterior attachments – their costal
cartilage is embedded into the lateral body wall muscle

The shoulder girdle

The pelvic girdle

4.3. PART 3: Joints
Joints/articulations: the sites where two or more bones meet. They have two
fundamental functions:

● Give the skeleton mobility

● Hold the skeleton together

4.3.1 Joint classification

Joints are classified by structure and function:

● Structurally - classification focusses on the material binding the bones

together and whether a joint cavity is present:
1. Fibrous
2. Cartilaginous
3. Synovial – only ones that have a joint cavity
● Functionally – classification is based on the amount of movement allowed at
the joint:
 1. Synarthroses – immovable
2. Amphiarthroses – slightly movable
3. Diarthroses – freely moveable

Fibrous joints
● The bones are joined by the collagen fibres of connective tissue
● No joint cavity
● Most are immoveable
● Three types:
1. Sutures (short fibres)
2. Syndesmoses (long fibres)
3. Gomphoses (periodontal ligament)

Cartilaginous joints
● Articulating bones are united by cartilage
 ● Lack a joint cavity
● Not highly moveable
● Two types
1. Synchondroses (hyaline cartilage)
2. Symphyses (fibrocartilage)

Synovial joints
● Articulating bones are separated by a fluid containing joint cavity
 ● Substantial freedom of movement
● Nearly all joints of the limbs fall into this class
● Six types
1. Plane
2. Hinge
3. Pivot
4. Condylar
5. Saddle
6. Ball and socket

General structure
● There are six distinguishing features to synovial joints:
● Articular cartilage – absorbs compression placed on the joint and keep bone
ends from being crushed
● Joint cavity – contains a small amount of synovial fluid, expands if fluid
accumulated as with what happens with inflammation
● Articular capsule – encloses the joint cavity. Two layered:
1. External fibrous layer – strengthens the joint so bones are not pulled
apart
2. Inner synovial membrane – covers all internal joint surfaces that are not
hyaline cartilage
1) The function is to make synovial fluid
● Synovial fluid – provides a slippery, weight-bearing film that reduces friction
between the cartilages
● Reinforcing ligaments – capsular ligaments reinforce and strengthen the
synovial joints
● Nerves and blood vessels – sensory nerve fibres innervate the capsule to
monitor joint position, stretch and pain. Blood vessels supply the synovial
membrane where capillary beds produce the blood filtrate that is the basis of
synovial fluid
Factors influencing synovial joint stability
Synovial joints are the weakest parts of the skeleton. Despite this, their structure
resists various forces that threaten to force them out of alignment. This depends on
three factors:

● The shapes of the articular surfaces – determine what movement is possible

at the joint
● The number and positioning of ligaments – unite the bones and prevent
excessive or undesirable motion. Theoretically, the more ligaments, the
stronger the joint is.
 ● Muscle tone – for most joints, the muscle tendons that cross the joint are the
most stabilising factor and are kept under tension by their muscles

Movements allowed by synovial joints

Every skeletal muscle of the body is attached to bone or other connective tissue
structures at no fewer than two points. The muscles origin is attached to the
immovable or less movable bone, and the insertion or other end is attached to the
movable bone. Movement occurs when muscles contract across joints and their
insertion moves toward their origin.

Bursae and tendon sheaths

These are not strictly part of synovial joints but are often found closely associated
with them. They are basically bags of lubricant they act as ball baring’s to reduce
friction between adjacent structures during joint activity.

● Bursae: flattened fibrous sacs lined with synovial membrane and containing a
thin film of synovial fluid.
● Occur where ligaments, muscles, tendons, skin or bones rub together
● Tendon sheath: elongated bursa that wraps around a tendon subjected to
friction

The problem with joints

Joint pain and malfunction can be caused by a number of factors besides trauma,
including inflammatory conditions and degenerative processes.

Common joint injuries

 ● Cartilage tears: occur when a meniscus is subjected to compression and
shear stress at the same time
1. As cartilage is avascular, unable to repair itself so will remain torn
unless repaired or damaged/ broken cartilage removed
● Sprains: ligaments reinforcing a joint are stretched or torn
1. Painful and immobilising
2. Partially torn ligaments will repair themselves, but as are poorly
vascularised, heal slowly
3. When ligaments are completely torn:
1) Torn ends can be sewn together but this is very difficult
2) Some are best repaired by grafting with a piece of muscle
tendon
3) Others need time and immobilisation
● Dislocations: occurs when bones are forced out of alignment
1. Usually accompanied by sprains, inflammation, and difficulty moving
the joint
2. Dislocations must be reduced, the bone ends must be returned to their
proper positions
3. Repeat dislocations are common due to the original dislocation
stretching the joint capsule and ligaments resulting in a loose capsule
providing poor reinforcement for the joint

Inflammatory and degenerative conditions

● Bursitis: inflammation of a bursa – usually caused by a blow or friction
1. Symptoms: pain and swelling
2. Treatment: anti-inflammatory’s and/or removal of excess fluid build-up
in the area by needle aspiration
● Tendonitis: inflammation of tendon sheaths – typically caused by overuse
1. Symptoms: pain and swelling
2. Treatment: rest, ice and anti-inflammatory’s
Arthritis
There are over 100 different types of inflammatory or degenerative diseases that
damage the joints. All forms of arthritis have the same initial symptoms:

● Pain
● Stiffness
● Swelling of the joint

Acute forms usually result from bacterial invasion and are treated with antibiotics

Chronic forms include:

● Osteoarthritis – most common chronic degenerative disorder

1. Most prevalent in aged
 2. Likely related to normal ageing process though may have a genetic
basic
3. More women than men affected
4. More cartilage is destroyed than replaced
5. The cause is slow and irreversible
6. Symptoms are controllable with anti-inflammatory’s and moderate
activities to keep joints mobile
● Rheumatoid arthritis - a chronic inflammatory disorder
1. Autoimmune disease – body’s immune system attacks its own tissues
2. Initial trigger is unknown
3. Begins with inflammation of the synovial membrane of the affected
joints
4. Usually arises between the ages of 30 -50
5. Affects 3 times as many women as men
6. Early stages – joint tenderness and stiffness are common
7. The course is variable and marked by flare-ups and remissions
8. Manifestations can include anaemia, osteoporosis, muscle weakness,
and cardiovascular problems
9. Severe cases can lead to ankylosis stage
10.The goal of current treatment is to go beyond the alleviation of
symptoms and disrupt destruction of joints by use of steroids, anti-
inflammatory’s, immune suppressants, and biologic agents to block the
action of inflammatory chemicals
11.As a last resort, joint replacement is an option for treatment
● Gouty arthritis (gout) – inflammatory response
● Excessive level of uric acid in the blood due to excessive production or slow
excretion can lead to deposits of urate crystals in the soft tissues of the joints
● Agonisingly painful
● Typically affects one joint – often base of the big toe
● Far more common in men
● Seems to be genetic
● Can be destructive – articulating bone ends can fuse and immobilise the joint
● Several drug treatment options that terminate or prevent attacks