Anatomy of bone

The skeletal system is divided into two functional parts: Axial skeleton --head , neck & trunk Appendicular--limbs( including pectoral and pelvic girdles)

The skeleton is made of cartilage and bones. The five major functions of the skeleton are: Support Protection Movement Storage Blood cell production

 Cartilage is a resilient, semirigid form of connective tissue that forms parts of the skeleton where more flexibility is recquired.
Bone is a living tissue which is a hard form of highly specialized connective tissue that makes up most of the skeleton.

Cartilage
Is an avascular form of connective tissue that consists of extracellular matrix embedded in a matrix that contains cells localized in small cavities. The amount and kind of extracellular fibers in the matrix varies depending on the type of cartilage.

The functions of cartilage are: Support soft tissues Provide a smooth, gliding surface for bone articulations at joints Enable the development joint lesions in sows. a: Cartilage erosion (arrows) and growth of Macroscopical on the medial humeral condyle. b: Cartilage ulceration (arrow) long bones on the medial femoral condyle. c: Cartilage repair (arrow) of the
medial femoral condyle d: Marginal osteophytes (arrows) on processus anconeus of ulna.

There are 3 types of cartilage: Hyaline-most common. Its matrix contains a moderate amount of collagen fibers( e,g. articular surfaces of bones) Elastic-matrix contains collagen fibers along with a large number of elastic fibers ( e.g external ear) Fibrocartilage-matrix contains a limited number of cells and ground substance amidst a substantial amount of collagen( e.g. intervertebral disc)

Bone
Consists of an intercellular calcified matrix, which also contains collagen fibers, and several types of cells within the matrix.

Bone Maturity woven ( immature bone) Here collagen fibres are aligned randomly and have no lamellae,making the bone weaker and more flexible than lamellar bone.

Lamellar ( mature) bone Forms the structural component of cortical and cancellous bone with stress-oriented collagen fibres contributing to its anisotropic characteristics.

 Histological cut showing details of lamellar bone concentrically organized and woven bone mixed with cartilage and calcified cartilage tissues (HE). Matos et al. Journal of Orthopaedic Surgery and Research 2008

 Two types of bones; compact and spongy bone( trabecular or cancellous). Compact bone is dense that forms the outer shell of all bones and surrounds spongy bone. Spongy bone consists of spicules of bone enclosing cavities containing blood-forming cells( marrow).

Cortical (compact bone)

Comprises of 80 % of adult skeleton forming th enevelope of cuboid bones and the diaphysis of long bones. Contains lamellae that are laid down as concentric rings forming trabecular lamellae systems called osteons or haversian systems.

Cancellous ( trabecular bone)

Found mainly in the metaphyses and epiphyses of long bones and centrally in cuboid bones. Its has a 3D lattice of interconnecting trabeculae which are aligned along axes of mechanical stress, enclosing elements of bone marrow. Each of the trabeculae is made up of parallel sheets of lamellae.

Classification of bones is by shape Long bones are tubular e.g humerus, femur Short bones are cuboidal e.g bones of wrist and ankle Flat bones consist of two compact bones plated separated by spongy bone e.g skull Irregular bones are bones with various shapes e.g bones of the face Sesamoid bones are round or oval bones that develop in tendons

Bone healing

Bone structure
All bones are derived from mesenchyme (embryonic connective tissue) by two different processes: Intramembranous ossification( directly from mesenchyme)-mesenchymal models of bones form during the embryonic period and direct ossification of the mesenchyme begins in the fetal period. Endochondral ossification( from cartilage derived from mesenchyme) cartilage models of the bones form from mesenchyme during the fetal period and bone subsequently replaces most of the cartilage.

Mesenchymal cells differentiate into chondroblasts-forming a cartilaginous bone model- midregion of cartilage calcifiesperiosteal capillaries( from fibrous sheath surrounding the model)- grow into the calcified cartilage of the bone model and supply its interior.

Most secondary ossification centres appear in other parts of the developing bone after birth; the parts of a bone ossified from these centres are epiphyses.
Epiphyseal arteries grow into developing cavities with associated osteogenic cells. The flared part of the diaphysis nearest the epiphyses is the metaphysis.

Gross Structures of Bone The gross structure of a long bone can be divided into several regions.
Epiphysis In the long bones, the epiphysis is the region between the growth plate or growth plate scar and the expanded end of bone, covered by articular cartilage. An epiphysis in a skeletally mature person consists of abundant trabecular bone and a thin shell of cortical bone.

 Cortical bone is composed of haversian systems (osteons). Each osteon has a central haversian canal and peripheral concentric layers of lamellae.

Metaphysis The metaphysis is the junctional region between the growth plate (see the image below) and the diaphysis. The metaphysis contains abundant trabecular bone, but the cortical bone thins here relative to the diaphysis. This region is a common site for many primary bone tumors and similar lesions.

Growth plate

The relative predilection of osteosarcoma for the metaphyseal region of long bones in children has been attributed to the rapid bone turnover due to extensive bone remodeling during growth spurts.

Diaphysis The diaphysis is the shaft of long bones and is located in the region between metaphyses, composed mainly of compact cortical bone. The medullary canal contains marrow and a small amount of trabecular bone.

Physis (epiphyseal plate, growth plate) The physis is the region that separates the epiphysis from the metaphysis. It is the zone of endochondral ossification in an actively growing bone or the epiphyseal scar in a fully grown bone.

Blood Supply
Bones are richly supplied with blood vessels. Most apparent are nutrient arteries that arise independent branches of adjacent arteries outside the periosteum and pass obliquely through the compact bone of the shaft of a long bone via nutrient foramina.

The nutrient artery divides in the medullary cavity into longitudinal branches that proceed toward each end supplying the bone marrow, spongy bone and deeper portions of compact bone.

The ends of bones are supplied by metaphysial and epiphysial arteries that arise mainly from the arteries that supply the joints; in the limbs these arteries are typically part of a periarticular arterial plexus, which surrounds the joint ensuring blood flow distal to the joint regardless of the position assumed by the joint.

The skeletal system receives 510 % of cardiac output. Individual long bones have 3 interactive circulatory systems all of which communicate in an adult. In children the metaphysealepiphyseal system separates when the ossific nucleus is formed.

1. Nutrient artery system 2. Metaphyseal-epiphyseal system 3. Periosteal system ( low pressure system)

Nutrient artery system-high pressure system

A major artery of the systemic circulation enters the middiaphysis through a nutrient foramen. Once in the medullary canal , it divides into ascending and descending arteries which anastomose with metaphyseal vessels and directly penetrate the endosteal surface,supplying the inner 2/3 rds of the cortex. In the child these vessels end on the metaphyseal side of the physis,contributing to the process of endochondral ossification.

Metaphyseal-epiphyseal system
The periarticular vascular complex penetrates the thin cortex and supplies the metaphysis, physis and epiphysis. The metaphyseal vessels anastomose with the medullary and epiphyseal arteries after growth plate fusion. In epiphyses with large articular surfaces, such as radial and femoral heads, vessels enter the bone between the articular cartilage and the physis, making the blood supply relatively tenuous.

Periosteal system(low pressure system)

Capillaries enter at the sites of major muscle attachments, normally supplying the outer third of the cortex. This is the dominant system in the child and is responsible for circumferential growth.

these 3 systems are interconnected, and each is able to become dominant supply if another is damaged. The normal direction of flow is centrifugal ( inside to out) but if endosteal system is damaged the periosteal system becomes dominant and the flow becomes centripetal ( outside to in).

Large irregular bones, short bones, and flat bones These bones receive a superficial blood supply from the periosteum, as well as frequently from large nutrient arteries that penetrate directly into the medullary bone. The 2 systems anastomose freely. Venous and Lymphatic Drainage of Bone Blood is drained from bone through veins that accompany the arteries and frequently leaves through foramina near the articular ends of the bones. Lymph vessels are abundant in the periosteum.

 Veins accompany arteries through the nutrient foramina. Lymphatic vessels are abundant in the periosteum.

Nerves accompany blood vessels supplying the bones. The periosteum is richly supplied with sensory nerves-periosteal nerves that carry pain fibres. Within bones, vasomotor nerves cause constriction or dilation of blood vessels, regulating blood flow through bone marrow.

Classification of joints

Blood supply of joints

Joints receive blood from articular arteries that arise from the vessels around the joint. The arteries often anastomose to form networks ( periarticular arterial anastomoses) to ensure blood supply to and across the joint in the various positions assumed by the joints.

Synovial joints include: Plane joints Hinge joints Saddle joints Condyloid joints Ball and socket joints Pivot joints

Synovial joints are also associated with bursae, which are flattened fibrous sacs lined with synovial membrane that develop in areas of friction. Tendon sheaths are special bursae that wrap around tendons in areas of friction.

Synovial fluid All freely moveable joints have some synovial fluid in them. Synovial fluid originates from plasma that is filtered by the capillary net and diffuses into the knee along with hyaluronic acid, which is locally synthesized. Synovial fluid transports nutrients, assists in the joint's defense, and lubricates the joint.

Blood supply to knee joint

Blood supply to skin around the knee is random (as opposed to axial) - intrinsic contributors to skin overlying knee are perforating branches of the superior and inferior genicular systems; - extrinsic supply: 3 sources; Descending genicular Recurrent branch of anterior tibial artery Descending branch of the lateral femorartery;

Pediatric Bone Circulation:

Circulation in pediatric bone: - differs from adult circulation due to requirements of growth & presence of epiphyseal plate - terminal branches of nutrient artery, along with metaphyseal vessels, approach growth plate in a parallel relationship - branches are so numerous as they reach growth plate that there is almost one vessel for each column of cartilage cells - in final few mm before terminal arteriole reaches cartilage, it is encased in a tube of enchondral bone

as vessel extends to end of cartilage column, it makes abrupt 180 deg turn to enter larger venule - slowing of the circulation may permit lodging & proliferation of bacteria to produce focus of hematogenous osteomyelitis - function of metaphyseal blood supply(metaphyseal side of growth plate) is to provide nutrition for active cells involved in endochondral ossification - epiphyseal vessels are essential for they supply dividing cells of growth plate & hence are responsible for maintaining longitudinal bone growth

References
Basic Orthopaedic Sciences ( The Stanmore guide) by Manoj Ramachandran Apleys System of orthopaedics and fractures Clinically oriented anatomy Grays anatomy for students Wheeless textbook of orthopaedics www.emedicine.medscape.com