Preface
Musculoskeletal system is one of the systems among all system in the body. This system has a major role in human movement and consists of bones, muscles, joints, tendons and ligaments including the neurovascular within the system. The knowledge of musculoskeletal system very useful to determine the normal condition and can be used to explain pathological concept of many disorders as a whole system. There several diseases in this system such as development disorders, infections, metabolism, neoplasm and weakness of muscles. Most of the diseases can be treated as soon as possible through holistic approach related to medical ethics and informed consent due to patient’s satisfaction.
Musculoskeletal system is explain the whole body and it's concept as a basic concept for the other block. That,s why this block is put in advance. Some concept will be studied again or will be used for the other block.
Musculoskeletal system and disorders will be studied based on case as a trigger. The case is one of examples of musculoskeletal disorders that are commonly finding the real situation. It’s needed comprehensive approach to understand this block base on basic knowledge, clinical and rehabilitation. Hopefully this book will be used as a trigger to study the core of musculoskeletal system and disorders and can be the basic concept to study the others especially in special study and special topics.
Best regards Planners
Introduction
Movement is very important in human life. Everyone should move as an adaptation to the entire environment even external or internal. Movement is generated by a specific stimulation. Proper stimulus will be processed through central and peripheral nerves system and deliver to muscles by axon and neuromuscular junction. The muscle will contract to pull the bone that is observed as a movement.
To get the optimum movement, there are many aspects should be considered such as bones, joints, ligaments, tendons, muscles and nerves. They all work together in a complex coordination to generate a movement according to the stimulus. This guide book will encourage all the students to comprehend all the topics through lecture, small group discussion, individual learning, student project and clinical skill. Student should know about bones and muscles since its developed, location, function and its disorders.
Disorder of musculoskeletal system could be as result of several condition such as development, metabolism, trauma, infection, degenerative or neoplasm. Any type of problems will need different approach of treatment such medical, operation, pharmacology and rehabilitation. Understanding of musculoskeletal can be used in phorensic aspect and for many purposes. The student comprehends all disorder as in real situation, so this guide book will provide some cases as a trigger for discussion. So, active participation of student is the most important aspect in learning by doing process, because all the topics should be discussed in small group under supervision of facilitator.
Lecturers who give a lecture in the class just give the student the concepts of every topics, and the student should explore and study insight under guidance of learning task and self assessment. The succesfull of this block is depending on your active participation in teching learning process.
Contents
1. Preface ……….1
2. Contents ………2
3. Contributors ………
a. Planners ……….4
b. Lectures ……… 4
c. Facilitators ………..5
4. Time Table Regular Class .………..6
5. Time Table English Class ………6
6. Students Meeting Representatives ………...10
7. Student Project ...10
8. Assessment ………..10
9. Learning Programme ………...11
10. References ……….62
Team of Musculoskeletal
System and Disorders
Planners and Resource Persons
No Name Department Phone
~ FACILITATORS ~
Regular Class (Class A)
No Name Group Departement Phone (3Venuerd floor) 1 dr. Putu Patriawan, Sp.Rad, MSc A1 Radiology 08123956636 3R.3.01nd floor: 2 dr. Ni Luh Ariwati A2 Parasitology 08123662311 3nd floor:R.3.02
3 dr. Ni Luh Putu Ratih Vibriyanti Karna, Sp.KK A3 Dermatology 081337808844 3nd floor:R.3.03
4 dr. Pratihiwi Primadharsini, M.Biomol, Sp.PD A4 Interna 081805530196 3nd floor:R.3.04
5 dr. Ni Made Dewi Dian Sukmawati, Sp.PD A5 Interna 081805656501 3nd floor:R.3.05
6 dr. Putri Ariani, Sp.KJ A6 Psychiatry 082237817384 3nd floor:R.3.06
7 dr Wayan Citra Wulan Sucipta Putri A7 Public Health 081805570772 3nd floor:R.3.07
8 dr. Ni Nyoman Margiani, Sp.Rad A8 Radiology 081337401240 3nd floor:R.3.08
9 dr. Putu Yuliandari, S.Ked A9 Microbiology 089685415625 3nd floor:R.3.20
10 dr. Nyoman Paramita Ayu, Sp.PD A10 Interna 08123837372 3nd floor:R.3.21
11 dr. Pontisomaya Parami, Sp.An A11 Anasthesi 0823661312 3nd floor:R.3.22
12 dr. I Gusti Made Gde Surya Chandra Trapika , M.Sc A12 Pharmacology 081337991177 3nd floor:R.3.23
English Class (Class B)
No Name Group Departement Phone (3rd floor)Venue
1 dr. Nyoman Suryawati , M.Kes, Sp.KK B1 Dermatology 0817447279 3nd floor:R.3.01
2 dr. Ni Nengah Dwi Fatmawati , Sp.MK, Ph.D B2 Microbiology 087862200814 3nd floor:R.3.02
3 dr. A.A.Ngurah Subawa , Msi B3 PathologyClinical 08155735034 3nd floor:R.3.03
4 Dr. dr. Bagus Komang Satriyasa, M.Repro B4 Pharmacology 087777790064 3nd floor:R.3.04
5 dr. Anak Agung Wiradewi Lestari, Sp PK B5 PathologyClinical 08155237937 3nd floor:R.3.05
6 dr. Ni Made Adi Tarini, Sp.MK B6 Microbiology 081338675344 3nd floor:R.3.06
7 dr. I G.A. Indah Ardani, Sp.KJ B7 Psychiatry 03618810404 3nd floor:R.3.07
8 dr. I Gusti Ayu Widianti , M.Biomed B8 Anatomy 08123921765 3nd floor:R.3.08
9 dr. Putu Ayu Asri Damayanti , M Kes B9 Parasitology 085338565783 3nd floor:R.3.20
10 dr. Putu Budhiastra, Sp.M(K) B10 Opthalmology 085238238999 3nd floor:R.3.21
11 dr. Ni Kadek Mulyantari , Sp PK B11 PathologyClinical 08123647413 3nd floor:R.3.22
Lecture Schedule
DAY / DATE ACTIVITY TIME VENUES CONVEYER RegularClass EnglishClass
1
16/
2
Intoduction : Human Movement Individual learning
SGD Break
Self Assessment and Student Project Plenary 08.00 – 09.00 09.00 – 10.30 10.30 – 12.00 12.00 – 12.30 12.30 – 14.00 14.00 – 15.00 09.00 – 10.00 10.00 – 11.30 13.30 – 15.00 12.00 – 13.30 11.30 – 12.00 15.00 – 16.00 Class room -Discussio n room -Class room Prof. Mangku -Facilitator -Prof. Mangku
2
17/
2
Lecture : Congenital Bone Disorder
Individual learning SGD
Break
Self Assessment and Student Project Plenary 08.00 – 09.00 09.00 – 10.30 10.30 – 12.00 12.00 – 12.30 12.30 – 14.00 14.00 – 15.00 09.00 – 10.00 10.00 – 11.30 13.30 – 15.00 12.00 – 13.30 11.30 – 12.00 15.00 – 16.00 Class room -Discussio n room -Class room Prof. Siki -Facilitator -Prof. Siki
3
18/
2
Lecture : Bone Development And It’s Microscopic Structure Individual learning
SGD Break
Self Assessment and Student Project Plenary 08.00 – 09.00 09.00 – 10.30 10.30 – 12.00 12.00 – 12.30 12.30 – 14.00 14.00 – 15.00 09.00 – 10.00 10.00 – 11.30 13.30 – 15.00 12.00 – 13.30 11.30 – 12.00 15.00 – 16.00 Class room -Discussio n room -Class room
dr. Lina, Dr. Adiatmika
-Facilitator
-dr. Lina, Dr.
Adiatmika
4
20/
2
Lecture : Bone And Metabolism Disorders
(Osteoporosis) Individual learning
SGD Break
Self Assessment and Student Project Plenary 08.00 – 09.00 09.00 – 10.30 10.30 – 12.00 12.00 – 12.30 12.30 – 14.00 14.00 – 15.00 09.00 – 10.00 10.00 – 11.30 13.30 – 15.00 12.00 – 13.30 11.30 – 12.00 15.00 – 16.00 Class room -Discussio n room -Class room Prof. Siki -Facilitator -Prof. Siki
5
23/
2
Individual learning SGD
Break
Self Assessment and Student Project Plenary 09.00 – 10.30 10.30 – 12.00 12.00 – 12.30 12.30 – 14.00 14.00 – 15.00 10.00 – 11.30 13.30 – 15.00 12.00 – 13.30 11.30 – 12.00 15.00 – 16.00 -Discussio n room -Class room -Facilitator -Dr. Mahendra Dewi
6
24/
2
Lecture : Orthopaedic Problem And Its
Management Individual learning
SGD Break
Self Assessment and Student Project Plenary 08.00 – 09.00 09.00 – 10.30 10.30 – 12.00 12.00 – 12.30 12.30 – 14.00 14.00 – 15.00 09.00 – 10.00 10.00 – 11.30 13.30 – 15.00 12.00 – 13.30 11.30 – 12.00 15.00 – 16.00 Class room -Discussio n room -Class room Dr. Elysanti, Prof. Astawa -Facilitator -Dr. Elysanti, Prof. Astawa
7
25/
2
Lecture : The Appendicular Skeleton
Individual learning SGD
Break
Self Assessment and Student Project Plenary 08.00 – 09.00 09.00 – 10.30 10.30 – 12.00 12.00 – 12.30 12.30 – 14.00 14.00 – 15.00 09.00 – 10.00 10.00 – 11.30 13.30 – 15.00 12.00 – 13.30 11.30 – 12.00 15.00 – 16.00 Class room -Discussio n room -Class room Prof. Mangku -Facilitator -Prof. Mangku
8
26/
2
Lecture : Bone Fracture Individual learning
SGD Break
Self Assessment and Student Project Plenary 08.00 – 09.00 09.00 – 10.30 10.30 – 12.00 12.00 – 12.30 12.30 – 14.00 14.00 – 15.00 09.00 – 10.00 10.00 – 11.30 13.30 – 15.00 12.00 – 13.30 11.30 – 12.00 15.00 – 16.00 Class room -Discussio n room -Class room dr. Wien Aryana -Facilitator -dr. Wien Aryana
9
27/
2
Lecture : Bone Joint, Tendons and Ligaments
Individual learning SGD
Break
10
2/3
Lecture : Bone And Immunology Disorder (Osteoarthritis and Gout
Arthtitis) Individual learning
SGD Break
Self Assessment and Student Project Plenary 08.00 – 09.00 09.00 – 10.30 10.30 – 12.00 12.00 – 12.30 12.30 – 14.00 14.00 – 15.00 09.00 – 10.00 10.00 – 11.30 13.30 – 15.00 12.00 – 13.30 11.30 – 12.00 15.00 – 16.00 Class room -Discussio n room -Class room Prof. Tjok Raka -Facilitator -Prof. Tjok Raka
11
3/3
Lecture : Skeletal Muscles Individual learning
SGD Break
Self Assessment and Student Project Plenary 08.00 – 09.00 09.00 – 10.30 10.30 – 12.00 12.00 – 12.30 12.30 – 14.00 14.00 – 15.00 09.00 – 10.00 10.00 – 11.30 13.30 – 15.00 12.00 – 13.30 11.30 – 12.00 15.00 – 16.00 Class room -Discussio n room -Class room dr. Ika Wahyuniari -Facilitator -dr. Ika Wahyuniari
12
4/3
Lecture : Muscle Contraction As A Trigger Of
Movement Individual learning
SGD Break
Self Assessment and Student Project Plenary 08.00 – 09.00 09.00 – 10.30 10.30 – 12.00 12.00 – 12.30 12.30 – 14.00 14.00 – 15.00 09.00 – 10.00 10.00 – 11.30 13.30 – 15.00 12.00 – 13.30 11.30 – 12.00 15.00 – 16.00 Class room -Discussio n room -Class room Dr. Adiatmika -Facilitator -Dr. Adiatmika
13
5/3
Lecture : Muscles - Deg Ds and RNA
Individual learning SGD
Break
Self Assessment and Student Project Plenary 08.00 – 09.00 09.00 – 10.30 10.30 – 12.00 12.00 – 12.30 12.30 – 14.00 14.00 – 15.00 09.00 – 10.00 10.00 – 11.30 13.30 – 15.00 12.00 – 13.30 11.30 – 12.00 15.00 – 16.00 Class room -Discussio n room -Class room dr. Susilawati, dr. Kambayana -Facilitator -dr. Susilawati, dr. Kambayana
14
6/3
Degenerative Disorders of Spine
Individual learning SGD
Break
12.30 – 14.00 14.00 – 15.00 11.30 – 12.00 15.00 – 16.00
room Ridia, dr.Suyasa
15
9/3
Basic Clinical Skill09.00 – 14.00
09.00 – 14.00
Anatomy Dept. (1st
fl) Histology Dept. (4th
fl) Physiolog
y Dept. (2nd fl)
Joint Laborator
y (4th fl)
Team
16
10/
3
Basic Clinical Skill 09.00 –14.00 09.00 –14.00
Anatomy Dept. (1st
fl) Histology Dept. (4th
fl) Physiolog
y Dept. (2nd fl)
Joint Laborator
y (4th fl)
Team
17
11/
3
Basic Clinical Skill 09.00 –14.00 09.00 –14.00
Anatomy Dept. (1st
fl) Histology Dept. (4th
fl) Physiolog
y Dept. (2nd fl)
Joint Laborator
y (4th fl)
Team
18
12/
3
Basic Clinical Skill 09.00 –14.00 09.00 –14.00
Anatomy Dept. (1st
fl) Histology Dept. (4th
fl) Physiolog
y Dept. (2nd fl)
Joint Laborator
y (4th fl)
Team
19
13/
3
Basic Clinical Skill 09.00 –
14.00 09.00 –14.00 Dept. (1Anatomyst
fl) Histology Dept. (4th
fl) Physiolog
y Dept. (2nd fl)
Joint Laborator
y (4th fl)
20
16/
3
Mid-Test 09.00 – 10.30 10.30 – 12.00 09.00 – 10.30 10.30 – 12.00 Class Room,Lab, SGD Team
21
17/
3
Lecture : Neoplasm Of Bone and Ulcer Individual learning
SGD Break
Self Assessment and Student Project Plenary 08.00 – 09.00 09.00 – 10.30 10.30 – 12.00 12.00 – 12.30 12.30 – 14.00 14.00 – 15.00 09.00 – 10.00 10.00 – 11.30 13.30 – 15.00 12.00 – 13.30 11.30 – 12.00 15.00 – 16.00 Class room -Discussio n room -Class room
dr. Eka W -Facilitator
-dr. Eka W
22
18/
3
Lecture : Bone Infections Individual learning
SGD Break
Self Assessment and Student Project Plenary 08.00 – 09.00 09.00 – 10.30 10.30 – 12.00 12.00 – 12.30 12.30 – 14.00 14.00 – 15.00 09.00 – 10.00 10.00 – 11.30 13.30 – 15.00 12.00 – 13.30 11.30 – 12.00 15.00 – 16.00 Class room -Discussio n room -Class room dr. Suryanto Dusak -Facilitator -dr. Suryanto Dusak
23
19/
3
Lecture : Musculoskeletal Rehabilitation Individual learning
SGD Break
Self Assessment and Student Project Plenary 08.00 – 09.00 09.00 – 10.30 10.30 – 12.00 12.00 – 12.30 12.30 – 14.00 14.00 – 15.00 09.00 – 10.00 10.00 – 11.30 13.30 – 15.00 12.00 – 13.30 11.30 – 12.00 15.00 – 16.00 Class room -Discussio n room -Class room dr. Tjok Dalem Kurniawan -Facilitator - -dr. Tjok Dalem Kurniawan
24
23/
3
Lecture : Bone Forensic Individual learning
SGD Break
25
24/
3
Lecture : NSAID And Muscle relaxant Individual learning
SGD Break
Self Assessment and Student Project
Plenary
08.00 – 09.00 09.00 –
10.30 10.30 –
12.00 12.00 –
12.30 12.30 –
14.00 14.00 –
15.00
09.00 – 10.00 10.00 –
11.30 13.30 –
15.00 12.00 –
13.30 11.30 –
12.00 15.00 –
16.00
Class room
-Discussio
n room -Class room
dr. Ngurah, dr. Wiwik
-Facilitator
-dr. Ngurah,
dr. Wiwik
ATT :
Pre-Evaluation Break
: 25 March 2015
Schedule
Basic Clinical Skill
DAY / DATE
ANATOMY DEPT
CLASS ROOM (PHYSICAL DIAGNOSTIC
MSD)
PHYSIOLOGY DEPT
JOINT LAB PATHOLOGY
ANATOMY 08.00 – 11.00
HISTOLOGY DEPT 11.30 – 14.30
15
9/3
A B C D E16
10/3
B C D E A17
11/3
C D E A B18
12/3
D E A B C19
13/3
E A B C DGroup Distribution Member
Basic Clinical Skill
GROUP REGULAR CLASS
(ABSENT NUMBER)
ENGLISH CLASS (ABSENT NUMBER)
A 1 – 60
B 11 – 120
C 121 – 148 1 – 32
D 33 – 92
E 93 – 146
Total Student 148 146
ATT :
Students Meeting Representatives
In the middle of block schedule, a meeting is designed among the student representatives of every small group discussion, facilitators and resource persons. The meeting will discuss the ongoing teaching learning process, quality of lecturers and facilitators as a feedback to improve the next process. The meeting will be held based on schedule from Medical Education Unit.
Student project and Individual Learing
For a more comprehensive achievement in studying the whole topics in this Block, the student must spend the time alocation properly including Individual Learing. At this time, the student must read the references and make synthesis from the references. The goal is the student could fullfil the learning objectives of each topic and in accordance to SKDI. As a proof of good individual learning process has been done properly, the student must write the synthesis for each topic during the Individual Learning session and must be showed and signed by the facilitator after SGD. Please completed the student project by handwriting, not by computer.
Assessment
Type of assessment is multiple choice questions (MCQ) and fill the blank and OSCE. A prerequisite condition to follow the assessment is attendance in at least 75% of all scheduled teaching-learning activities and follows the questionnaire test during lecture. Students’ assessment consists of summative assessment that is given at the end of lecture. Main examination be held at 2 6 March 2015 and OSCE will be conducted together with other block at semester IV.
LEARNING PROGRAM
MODULE
1
HUMAN MOVEMENT - THE AXIAL SKELETON
Prof. Dr. dr. Mangku Karmaya, M.Repro
AIMS:
Describe the common functional of musculoskeletal system related to musculoskeletal disorders
LEARNING OUTCOME:
1. Describe the role of musculoskeletal system 2. Describe the element of musculoskeletal system 3. Describe the function of musculoskeletal
4. Describe the development of MSDs CURRICULUM CONTENTS:
1. Role of musculoskeletal system 2. Element of musculoskeletal system 3. Function of musculoskeletal
4. Development of MSDs ABSTRACTS:
Musculoskeletal system consists of muscles and bones. Muscles are connected with bones, cartilages, ligaments and skin either directly or through the intervention of fibrous structures called tendons or aponeurosis.
Muscles are various in their form, arrangement and size. So there are terms considering the form as long, broad, short, etc., used in the description of a muscle. The terms quadrilateral, fusiform, triangular, oblique, penniform, bipeniform, sphincter are correlate with muscle arrangement. Gastrocnemeus, sartorius and stapedius are terms according to their size.
Name of the muscles are derived from: (1) their situation, as the Tibialis, Radialis, Ulnaris, Peroneus; (2) their direction as the Rectus abdominis, Obliqui capitis, Transversalis; (3) their uses, as Flexors, Extensors, abductors etc. (4) their shape as Deltoid, Rhomboid, Trapezius; (5) the number of their division as the Biceps, the Triceps; (6) the points of attachment as the Sternocleidomastoideus, Sternothyroid, Sternothyroid.
It is very important to know the exact origin and insertion because it is of great importance in the determination of their action. There is a number of actions: flexion, extention, abduction, adduction, rotation, circumduction, supination, pronation, protrusion
(protraction), retrusion (retraction), elevation and depression. Also the relation of the muscles especially those in immediate apposition with the larger blood vessels and the surface marking they produce should be remembered as they form useful guides in the application of a ligature to those vessels.
The fibrous tisssues are in close relation with the muscle. They are tendons and aponeurosis. They are connected, on the one hand, with the muscles and, on the other hand with the movable structures as bones, cartilages and fibrous membranes.
The skeleton of the body is composed of bones and cartilages. Bones provide protection for vital structures, support for the body, the mechanical basis for movement, storage for salts (e.g., calcium) and a continuous supply of new blood cells. Cartilage forms parts of the skeleton where more flexibility is necessary as yhe costal cartilage and articular cartilage.
There are two types of bones: compact and spongy; its architecture varies according to function. Compact bone provides strength for weightbearing. Bones are classified according to their shape: long, short, flat, irregular and sesamoid bone.
The skeleton system has two main parts: the axial skeleton consist of the bones of the head, neck and trunk and appendicular skeleton consist of the bones of the limbs, including those forming the pectoral and pelvic girdles.Thoracic skeleton (bony thorax) dibentuk oleh 12 pasang costae (ribs) dan costal cartilages, 12 thoracic vetebrae dan intervertbral disc dan sternum.
SELF DIRECTING LEARNING
Basic knowledge that must be known: 1. Functions of bones and muscles
2. Name of skeletal muscles according to their location, attachment, form, direction of the fibers and its function
3. Parts of bones and muscles
4. Clinical aspects of musculoskeletal system and its implications SCENARIO
Case 1
A 65-year-old man and a14-year-old boy were involveed in severe automobile accident. In both patients the thorax had been badly crushed. X-ray examination revealed that the man had five fractured ribs but the boy had no fractures.
Learning task
1. What is the most likely explanation for this difference in medical findings? 2. Explain why the last two ribs are prone to fracture?
3. Describe the type of the ribs and how they joint with other bones. Case 2
A medical student offered to move a grand piano for his landlady. He just finished his final examinations in Anatomy and was in poor physical shape. He strugled with the antique monstrosity and suddenly experienced an acute pain in the back, which extended down the back and outer side of his left leg. On examination in the emergency department, he was found to have a slight scoliosis with the convexity on the right side. The deep muscles of the back in the left lumbar region felt firmly than normal. No evidence of muscle weakness was present, but the left ankle jerk was deminished. The symptoms and signs of the patient strongly suggested a diagnosis of prolapsed intervertebral disc.
Learing task
2. What is the normal position of lumbar vetebrae in erect position? 3. Compare the lumbar vertebrae with other vertebrae.
4. Describe all muscles that construct the back Case 3
A 45-year-old man was seen in the emergency department after beeing knock down in a street brawl. He had received a blow on the right head with an empty bootle. On
examination the patient was conscious with swelling on his upper right head and right face. The head skin is intact and he could not move his lower jaw.
Learning task
1. What layer of SCALP the hematoma occupied?
2. If the lateral side of cranium was injured, what muscles and bones are suffered? 3. What probably occured to him so he could not move his lower jaw?
4. What structures involve in temporomandibular joint movement? Self assessment
1. Describe the functions of bones and muscles
2. Describe the name of skeletal muscles according to their location, attachment, form, direction of the fibers and its function
3. Discribe the parts of bones and muscles
4. Describe some clinical aspects of musculoskeletal system and its implications 5. Describe the name of bones that construct the axial skeleton
MODULE
2
CONGENITAL BONE DISORDER
Prof. Dr. dr, I Ketut Siki Kawiyana,SpB. SpOT(K)
AIMS:
Establish tentative diagnosis, provide initial management and/or refer patient with congenital anomaly of musculoscletal system.
LEARNING OUTCOME:
Establish tentative diagnosis, provide initial management and/or refer patient with
o CTEV
o CDH
CURRICULLUM CONTENTS:
1. Principle management of congenital anomaly of musculoscletal system.
2. Establish tentative diagnosis, provide initial management and/or refer patient with a. CTEV
b. CDH ABSTRACTS
CTEV (Congenital Talipes Equinovarus).
Synonym is a Clubfoot. It is a common birth defect, occurring in about one in every 1.000 live birth. Approximately 50% of case of clubfoot is bilateral. In most case it is an isolated dysmelia. Incidence in males is slightly higher than females.
Cause: There is different cause for clubfoot. It is not known what the exact cause of clubfoot may be, but it has be found common in individuals with Edwards syndrome, a genetic defect, external influences such as intrauterine compression from oligohydramnion or from amniotic band syndrome. CTEV may be associated with use of medicamentous while pregnant.
Clinical sign: The foot is twisted in (inverted) and down. The deformities are Equinus of the ankle, varus of hind foot, supination of midfoot, and adduction of forefoot. Without treatment, person afflicted often appear to walk on their ankles, or on the sides of their feet.
Treatment: Clubfoot is treated by non operative or operative. By non operative, clubfoot is treated with manipulation and is followed by serial casting, most often by the Ponseti Method. Foot manipulation is usully done as soon as possible or within two weeks of birth. Even with successful treatment, when only one side is affected. Surgery is indicated in rigid or neglected clubfoot. In the chilled under 5 years old, posteromedial soft tissue release must be done, there are ATL, lengthening of tibialis posterior tendon, flexor digitorum and flexor hallucis tendon, and release, and release all of ligament and joint
capsule on the medial foot and ankle. In chilled over then 10 years old, bone procedure must be done.
DDH (Developmental Dysplasia of Hip)
Developmental Dysplasia of Hip is congenital (present at birth) condition of the hip joint. It occurs once in every 1.000 live birth. The hip joint is created as a ball and socket joint. In DDH, the hip socket may be shallow, letting the “ball” also known as the femoral head, slip in and out of the socket. The femoral head may move partially or completely out of the hip socket.
Cause: The greatest incidence of DDH occurs in first-born females. Hip dysplasia is considered a “multifactorial trait”. Multifactorial inheritance means that many factors are inveloved in causing a birth defect. The factors are usually both genetic and environmental. The risk factors for DDH are:
- Family history of developmental dysplasia of the hip, or very flexible ligament. - Position of the baby in the uterus, especially with breech presentations.
- Associations with other orthopaedic problems that include metatarsus adductus, clubfoot, and arthrogryposis multiplex congenital.
Diagnosed of DDH: The symptoms and sign may include: - The leg may appear shorter.
- The leg turns outward.
- The folds in the skin of tight or buttocks may appear uneven. - The space between the legs may look wider than normal. Diagnostic procedure may include:
- X-ray of the pelvis.
- Ultra sound (Sonography).
- CT scan (Computed tomography scan). - MRI (Magnetic resonance imaging).
Treatment for DDH: The goal of treatment is to put the femoral head back into the socket of the hip, so that the hip can develop normally.
Treatment options vary for babies and may include: - Placement of a Pavlik harness.
- Traction and casting. - Surgery and casting. SELF DIRECTING LEARNING
Basic knowledge that must be known: 1. Concept of congenital abnormalities 2. Type of congenilat abnormalities
3. Management patient with congenital abnormalities SCENARIO
Case I
A lecturer showed one of his medical students, a 4 months old female patient with abnormalities in her left lower limb, shortening in her thigh, adducted and difference in skin fold between her right and left thighs. Lecturers said this patient might be having DDH (Developmental Dysplasia of the Hip)
1. Where is the abnormality occured and why is it called DDH? 2. What are the incidence, etiology and pathogenesis of DDH?
3. How do you diagnosed and treat DDH patient based on age of the patient?
Case II
She has a daughter studying in medical faculty. She asked her daughter about the abnormalities in this baby and how to treat this baby appropriately.
1. What are the congenital abnormalities found in lower limb? 2. What are the causes of bowed legs?
3. In this case, what are the deformities found in leg and ankle?
4. How do you manage this baby and when do you start the treatment? Case III
A newborn baby found born with both of his legs bowed inwards 1. What are the congenital abnormalities found in this baby?
2. What are the radiologic examinations needed to be done for this patient? 3. What are the radiologic imaging are expected in this patient?
Learning Task:
1. Definition of congenital abnormalities in musculoskeletal system 2. Congenital abnormalities that is common found
3. Signs and diagnostic criteria 4. Management procedures
5. Consultation patient with congenital abnormalities Self Assessment:
1. What is the meaning of congenital abnormalities?
MODULE
3
BONE DEVELOPMENT AND ITS MICROSCOPIS STRUCTURE
dr. Ni Made Linawati, M.Si
Dr. dr. I Putu Gede Adiatmika, M.Kes
MICROSCOPICS OF BONE
AIMS :
1. Describe normal bones as structure and bone as an organ and apply its concepts and principles in the approach of patient with healing/injury
2. Describe several factors that affect to regulation of calcium and bone remodeling in the patient with healing/injury
LEARNING OUTCOME:
1. Comprehend the concept of microscopic bone structure and it’s development 2. Apply the concept to clinical case such as osteoporosis, bone fracture
3. Comprehend the physiology of calcium and its regulation within the body. 4. Apply the concept calcium balance to bone fracture / injury
CURRICULUM CONTENTS: a. Bone :
Intra membraneous ossification
Endochondral Ossification
Compact / lamellar bone
Woven bone b. Cartilage :
Hyaline cartilage
Elastic cartilage
Fibrocartilage c. Bone development
d. Bone deposition, bone absorption
ABSTRACTS
Cartilage and Bones
Cartilage is characterized by an extracellular matrix enriched with glycosaminoglycans and proteoglicans, macromolecules that interact with collagen and elastic fibers. Variations in the compositione matrix component produce 3 types of cartilage adapted to local biomechanical needs. Cartilage consists of cells called chondrocytes and an extensive extracellular matrix composed of fibers and ground substance. Condracytes synthesize and secrete the extracellular matrix and the cells themselves are located in
matrix cavities called lacunae. There are three forms of cartilage: hyaline cartilage, elastic cartilage and fibrocartilage.
Bone is specialized connective tissue composed of intercellular calcified material, the bone matrix, and 3 cell types: osteocytes, osteoblasts and osteoclast. Microscopic examination of bone shows 2 varieties: primary, immature or woven and secondary, mature or lamellar bone. Bone can be formed in 2 ways: by direct mineralization of matrix secreted by osteoblast (intramembranous ossification) or by deposition of matrix on a pre-existing cartilage matrix (endochondral ossification).
Jointregions were bones that are capped and surrounded by connective tissue that hold the bones together and determine the type and degree of movement between them. Joint may be classified as synostosis, synchondrosis and syndesmosis. In synostosis, bone is united by bone tissue and no movement takes place. In children and young adult, are united by dense connective tissue. Synchondroses are articulations in which the bone is joined by hyaline cartilage. Diarthroses are joints that generally unite long bones and have great mobility. In this joint, ligament and a capsule of connective tissue maintain the contact at the end of bone. The articular surfaces of a diarthrosis are covered by hyaline cartilage that is devoid of perichondrium. The capsule of dioarthroses varies in structure according to the joint. Generally, this capsule is composed of 2 layers, the external fibrous layer and the internal synovial layer. The synovial layer is formed by two types of cells. One resembles fibroblast and the other has the aspect and behavior of macrophages. The fibrous layer is made of dense connective tissue.
Bone growth and remodeling
Bone growth was affected by several factors such genetics, nutrition, endocrine dan nerve. Bone tissue development consists of primary and secondary process. Osteogenesis is the process of bone growth until 18 years old for female and 21 years old for male. Osteoblasts will secret osteoid, as one kind of collagen fibers which not yet reach for the classification process. Calcificaton process occurred about 1 week.
Active substance of vitamin D (1,25-dyhidroxycholecalciferal) was arranged through skin where the 7-dehydrocholesterol was changed to vitamin D3. The vitamin D3 will be changed to be 25-hydroxycholecalciferol within the liver. The 25-hydroxycholecalciferol will be changed to be 1,25-dyhydroxycholecalciferal within the renal cortex. This process supported by parathyroid hormone. Meanwhile, calcium absorption was occurred in the intestine and affected by 1,25 dyhydroxycholecalciferol within intestine epithelial.
Bone remodeling was affected by (1) mechanical stress that stimulates the bone harder at the stress point. ; (2) Parathyroid hormone and 1,25-dyhydroxycholecalciferol that stimulates osteoclast activity; and (3) calcitonin that decreasing osteoclast absorption capacity and reducing new osteoclast development. Bone remodeling was a dynamic process for long life and a balance process of osteoblast dan osteoclast function.
SELF DIRECTING LEARNING
Basic knowledge that must be known: 1. Microscopic view of bone cell 2. Composition of bone cell 3. Bone development 4. Calcium balance 5. Bone remodeling SCENARIO
Learning Task :
1. Describe the histogenesis of cartilage
2. Describe the normal structure and function of hyaline, elastic and fibrocartilage
3. Describe the microscopic structure of osteoprogenitor cells, osteoblast, osteocyte, osteoclast and bone matrix
4. Describe the organization of immature and lamellar bones 5. Describe the histogenesis of bones, included :
a. Intramembraneous and endochondral ossification b. Growth in length of long bones
c. Growth in diameter of long bones d. Surface modeling of bones
6. Describe the histology structure of articular surface of joint. Self Assesment
1. Chondrogenesis (cartilage growth) takes place by two mechanisms: (1)……….. and (2) ………..
2. The two major cell components of bone are the ……….. and……… 3. Explain the process of bone growth and remodeling
SCENARIO
A woman, 45 years old, come to hospital for thyroid and parathyroid surgery. For the preparation, the patient must do some assessment and therapy a better result after surgery. Learning Task :
1. Identify any assessment that must done by this patient.
2. Explain what the effect of parathyroid surgery to the other organ and calcium balance.
Self Assesment
1. What is the effect of parathyroid surgery ?
2. What should be given to patient to avoid hypocalcemia ?
3. What is the mechanism of organ to anticipate loss of parathyroid organ after the surgery ?
Reference:
1. Junquera LC. 2003. Cartilage and Bone in Basic Histology tenth edition. P. 135-156 2. Textbook of Medical Physiology, 10th ed, A.C. Guyton, Hall, Philadelphia, WB
MODULE
4
BONE AND METABOLISM DISORDERS
Prof. Dr. dr. I Ketut Siki Kawiyana, SpB. SpOT (K)
AIMS:
Establish tentative diagnosis, provide initial management and/or refer patient with methabolic disorders.
LEARNING OUTCOMES:
Establish tentative diagnosis, provide initial management and/or refer patient with : osteoporosis, rickets osteomalacea.
CURRICULUM CONTENTS: 1. Osteoporosis
2. Rickets
3. Osteomalacea. ABSTRACTS
OSTEOPOROSIS
Osteoporosis is a disease that thins and weakens the bones to the point that they become fragile and break easily. Women or men with osteoporosis most often break bones in the hip, spine, and wrist, but any bone can be affected.
Osteoporosis is often called “silent” because bone loss occurs without symptoms. People may not know that they have osteoporosis until a sudden strain, bump, or fall causes a bone to break. Bone is living tissue. Throughout our live, the body breaks down old bone and replaces it with new bone (remodeling). But as people age, more bone is broken down than is replaced. The bone will become thin and porous (osteoporosis).
Risk Factor: - Gender. - Age. - Ethnicity. - Family history.
- Life style: diet, Calcium, vit D, - Physical activity.
- Smoking
- Low body weight - Medication Sign and Diagnosis:
Osteoporosis does not have any symptoms until a fracture occurs, most often break bones in the hip, spine, and wrist. If spine fractures, height loss, back pain, back fatigue, curved spine.
The best screening test is dual energy X-ray absorptiometry (DEXA). This procedure is quick, simple and gives accurate results. It measures the density of bone in spine, hip and wrist.
Treatment & drugs:
Prescription drugs can help slow bone loss and may even increase bone density over time. It was including: hormonal therapy, bisphosphonates, and calcitonin.
Prevention:
Getting adequate calcium and vitamine D is an important factor in reducing risk of osteoporosis. Other tips for prevention: exercise, add soy to diet, don’t smoke, avoid excessive alcohol, and limit caffeine.
SELF DIRECTING LEARNING
Basic knowledge that must be known: 1. Clinical aspect of Osteoporosis 2. Differential diagnosis of osteoporosis 3. Management of osteoporosis.
SCENARIO
A 60 year old woman came to the orthopaedic clinic due to pain on her back since a year ago and already got treatment from general practitioner. She said that her back start to bent since 3 months and severe pain since yesterday because of fall down in sit position. She had gynecological operation when she was 40 year old
1. Please make imaginative anamnesis in this patient to lead to osteoporosis diagnosis.
2. What is the Differential Diagnosis? Please explain other examinations which can distinguish the DD.
3. What is the definition of osteoporosis? 4. What is the pathogenesis?
5. Is osteoporosis happened in female only? 6. How to prevent it?
7. In which bone, can fracture happened if this patient fell down? Learning Task:
1. Osteoclast and osteoblast function 2. Bone remodeling process
3. Factors that affect bone remodeling Self Assessment:
1. What is the osteoporosis classification?
MODULE
5
PATHOLOGY ANATOMY OF MUSCULOSKELETAL DS
Dr. dr. I G.A.Sri Mahendra Dewi, SpPA
AIM:
Describe the etiopathogenesis and morphologic features of musculoskeletal diseases and apply it concept for approach of musculoskeletal problems and its therapy. LEARNING OUTCOMES :
1. Bone
1.1 describe the effect (etiopathogenesis and morphologic features) of stress/ injury/ disease to bone.
2. Joint
2.1 describe the effect (etiopathogenesis and morphologic features) of stress/ injury/ disease to joint.
3. Muscle
3.1 describe the morphologic features of skeletal muscle tumors. 3.2 describe the morphologic features of smooth muscle tumors. 4. Soft tissue
4.1 describe the morphologic features of adipose tissue tumors. 4.2 describe the morphologic features of fibrous tissue tumors. CURRICULUM CONTENTS
1. Bone
1.1 Congenital and Hereditary Diseases of Bone : Achondroplasia, Osteogenesis Imperfecta
1.2 Osteoporosis and Acquired Metabolic Diseases (Rickets and Osteomalacia) 1.3 Osteomyelitis and Spondilitis
1.4 Bone Tumors : primary and secondary bone tumors, osteosarcoma, Ewing sarcoma, fibrous dysplasia
2. Joint : arthritis (gout arthritis and infectious arthritis), osteoarthritis, 3. Muscle : rhabdomyosarcoma, leiomyoma, leiomyosarcoma
4.Soft tissue : adipose tissue tumors (lipoma, liposarcoma), fibrous tissue tumors (fibroma, fibrosarcoma)
ABSTRACT
1. BONE
Achondroplasia is an inherited disorder characterized by impaired maturationof cartilage in the developing growth plate. The most conspicuous changes are marked, disproportionate shortening of the proximal extremities, bowing of the legs, and a lordotic
(sway-backed) posture. The cartilaginous growth plates contain hypoplastic or disorganized aggregates of chondrocytes instead of the long, orderly columns normally seen at this site.
Osteogenesis Imperfecta (OI) or brittle bone disease, is a group of hereditary conditions characterized by abnormal development of type I collagen. Type I collagen is present in many different tissues, including skin, joints and eyes. OI characterized by the present of multiple bone fractures. Other tissues containing type I collagen are also affected, resulting in abnormal dentition, hearing loss, and blue appearance to the sclera.
Osteoporosis is a skeletal disorder characterized by low bone mass and microarchitectural deterioration with a subsequent increase in bone fragility and susceptibility to fracture. It occurs most commonly as primary disorders or secondary. Osteoporosis result when imbalance occurs between bone formation and resorption. The hallmark of osteoporosis is a loss of bone, the bony trabeculae are thinning and widening of haversian canal.
Both rickets and osteomalacia are manifestations of vitamin D deficiency. The fundamental change in these diseases is defective mineralization of bone, accompanied by an increase in nonmineralized osteoid. In rickets, the defective mineralization involves the developing bones in children, but osteomalacia involves the bone that has completed its normal development.
Osteomyelitis designated as inflammation of the bone and marrow cavity by infectious agents. Osteomyelitis may be an acute or chronic. The most common etiologic agents are pyogenic bacteria and mycobacterium tuberculosis. Morphologically acute pyogenic osteomyelitis characterized by an intense, neutrophilic inflammatory infiltrate. Chronic osteomyelitis show sequestrum, involucrum and Brodie abscess. Tuberculous osteomyelitis causes the granulomatous inflammatory reaction.
Bone tumors divided in two categories : bone-forming tumors (osteoma, osteoid osteoma and osteoblastoma, and osteosarcoma) and cartilaginous tumors (osteochondroma, chondroma, and chondrosarcoma).
- Osteosarcoma is malignant mesenchymal neoplasm in which the neoplastic cells produce osteoid. Most unknown etiology. The lesion usually in the mataphyseal region of the bone, often elevates the periosteum toproduce the Codman triangle on radiographs. The hallmark of osteosarcoma is the formation of osteoid by malignant mesenchymal cells, that may be spindle shaped, pleomorphic, bizarre, and giant cell often present.
- Osteochondroma is benign proliferations composed of mature bone and a cartilaginous cap. Probably represent malformations rather than true neoplasm.
- Chondrosarcoma is malignant neoplasm populated by mesenchymal cells that produce a cartilaginous matrix. Microscopically, chondrosarcoma vary great in appearance. There are well, moderately or poorly differentiated malignant cells, multinucleate cells are present with lacunae containing 2 or more chondrocytes. - Ewing sarcoma occurs predominantly in children and adolescents, with a peak
incidence in the second decade of life. Ewing sarcoma arises within the medullary cavity of the affected bone to produce a soft, expansile mass. Microscopically it composed of sheets of primitive cells, with small, fairly uniform nuclei and only scant cytoplasm.
- Fibrous dysplasia is an uncommon, benign, tumor-like lesion of bone, in which the normal trabecular bone is replaced by proliferating fibrous tissue and disorderly islands of malformed bone.
2. JOINT
Additional bone proliferation occurs at the margins of the joints to produce bony excrescences, termed osteophytes. Non specific inflammation can develops.
Gout is a disorder caused by the tissue accumulation of excessive amounts of uric acid, an end product of purine metabolism. The major morphologic manifestation of gout are acute arthritis, chronic tophaceous arthritis and soft tissue tophi, and gouty nephropathy.
The most common form of infectious arthritis is caused by bacteria. The usual reaction manifested by local pain, fever and an intense neutrophilic inflammatory infiltrate within the joint and periarticular tissues.
3. MUSCLE
Rhabdomyosarcoma is predominantly a neoplasm of infancy, childhood and adolescence, with the peak incidence in the first decade of life. Microscopically there are three variants : embryonal, alveolar and pleomorphic.
Leiomyoma is common benign smooth muscle tumors, encountered most frequently in the uterus, composed of hyperplasia of smooth muscle cells arrayed in whorled-like without anaplastic appearance.
Leiomyosarcoma is malignant smooth muscle tumors, occur most often in the uterus and gastrointestinal tracts, composed of hyperplasia of smooth muscle cells with anaplastic appearance, with infiltrative growth.
4. SOFT TISSUE
Soft tissue tumors are generally classified on the basis of tissue type that they recapitulate, including tumors of adipose tissue (lipoma and liposarcoma), tumors of fibrous tissue (fibroma and fibrosarcoma). Lipoma is benign tumor, soft, yellow mass, composed of mature adipose tissue. Liposarcoma is malignant neoplasm, a number of different histologic subtypes are recognized, including well-differentiated, myxoid, round cell, pleomorphic and dedifferentiated liposarcoma. Fibrosarcoma is malignant neoplasm, composed of interlacing fascicles of fibroblast, sometimes arranged in a ‘herringbone’ pattern.
SCENARIO
A 72 years old woman came to a general hospital with chief complain pain and swelling in proximal region of her right lower extremity, after she fall in the bathroom. Radiograph examination showed fracture of femoral neck and decreased of bone density. Learning task :
1.1 What is the possible diagnosis of this patient ? 1.2 What are the role of hormonal factors in this case ?
1.3 Describe the morphologic features of the femoral bone of this patient.
A 22 years old man came to a doctor with chief complain swelling and pain in his knee, enlarge fast since a week ago. Radiograph examination showed lesion in metaphyseal region of distal femur, destroy the cortex, elevate periosteum and extend into the soft tissue. Biopsy was done in this patient.
Learning task :
2.1.What is the possible diagnosis of this patient ?
2.2 Describe the morphologic features of the biopsy specimen.
A 35 years old man came to a general hospital with chief complain subcutaneous masses, enlarge slowly since about 3 years ago, without pain. Biopsy was done in this patient. The result of histopathological examination was lipoma.
Learning task :
3.2 Mention some histopatological variant of lipoma. Self Assessment
1. BONE
1.1 Disorders of the skeletal system can occur in many nutritional and endocrine disorders. Describe the morphologic appearance of osteoporosis.
1.2 The most common etiologic agents of osteomyelitis are pyogenic bacteria and Mycobacterium tuberculosis. Describe the macroscopic and microscopic appearance of acute & chronic osteomyelitis, and tuberculous osteomyelitis.
1.3 Diagnosis of bone tumors require integration of the clinical history, radiologic, macroscopic and microscopic appearance of the tumor. Describe the macroscopic and microscopic appearance of the :
1.4 Bone-forming tumor (osteoma, osteoid osteoma and osteoblastoma, and osteosarcoma).
1.5 Cartilaginous tumors (osteochondroma, chondroma and chondrosarcoma).
2. JOINT
2.1 The most common disorder of the joints is degenerative joint disease. Describe some sequences in morphologic appearance of that disorder.
2.2 Gout arthritis is caused by the tissue accumulation of excessive amounts of uric acid. There are four major morphologic manifestations of gout arthritis. Describe the four manifestation above.
2.3 The most common form of infectious arthritis are caused by bacteria. Describe the macroscopic and microscopic appearance of acute suppurative arthritis.
3. MUSCLE
3.1 Describe the macroscopic and microscopic appearance of rhabdomyosarcoma 3.2 Describe the macroscopic and microscopic appearance of leiomyoma and
leiomyosarcoma 4. SOFT TISSUE
Describe the macroscopic and microscopic appearance of soft tissue tumor : - adipose tissue : lipoma and liposarcoma
- fibrous tissue : fibrosarcoma
Learning Resources :
Robbins Basic Pathology, 7 th ed, Kumar V, Cotran RS, Robbins SL. WB Saunders,
MODULE
6
ORTHOPAEDIC PROBLEM AND ITS MANAGEMENT
Dr. dr. Elysanti Danun, SpRad
Prof. Dr. dr. Putu Astawa, SpOT(K), M.Kes
AIMS:
Describe the clinical management of musculoskeletal disorders (Dx, RO”, Lab. Th. medical, operative and rehabilitation)
LEARNING OUTCOMES:
Describe how to: 1. Diagnosis 2. Rontgen 3. Laboratory
4. Therapy (medical, operative and rehabilitation) CURRCIULUM CONTENS:
1. history taking, (fundamental four and secret seven) of MSD’s 2. physical examination of MSD’s
3. investigation routine and specific of MSD’s 4. modality of treatment of MSD’s
ABSTRACTS (Prof. Dr.dr. Putu Astawa, SpOT(K). M.Kes)
The clinical management of musculoskeletal disorders consists of how to make a proper diagnosis through good anamnesis, physical examination, rontgen, and laboratory and give the patient proper treatment with medical, operative and rehabilitation modality. SELF DIRECTING LEARNING
Basic knowledge that must be known:
1. The procedure of musculoskeletal disorders diagnosis 2. Management of musculoskeletal disorders
3. Imaging for musculoskeletal disorders SCENARIO
Ten years old boy came to orthopaedic clinic with main complain swollen in the right knee due to trauma 1 week ago. The swollen has already developed before trauma and pain has already developed several months before. Patient’s bodyweight felt decrease 1 month ago. No fever.
Learning Task:
1. From the story above, what need to be asking to the patient? (Remember the secret seven and fundamental four).
2. Make the physical examination of this patient with imagination in correlation with the story above.
3. What is the differential diagnosis of this patient?
4. Please explain the pathogenesis from each of the differential diagnosis that has been mentioned above!
5. What is the planning diagnosis that you suggest?
6. If you want to make an X-ray, how to make a good photo? (Remember the rule of two).
7. How to read an X-ray photo of bone in generally?
8. If you doubt in make a diagnosis then need a biopsy and pathological examination. How is the general pathological appearance of chronic infection, TBC and bone malignancy?
Self Assessment:
1. How to do a good anamnesa in musculoskeletal cases
2. How to do a good physical examination in musculoskeletal cases
3. What is the laboratory findings that need to be checked in musculoskeletal cases 4. How to do radiologic imaging and reading in musculoskeletal cases
5. What is the etiology of musculoskeletal cases in general
LEARNING OBJECTIVE
Describe Radiological Imaging in Musculoskeletal System ABSTRACTS (Dr. dr. Elysanti Danun, Sp Rad.)
Evaluating the radiology imaging, it is important to evaluate the condition of soft tissue, bones and joint. Remember rule of two in making x-rays. So after studying the musculoskeletal topic, the students are expected to diagnose the mormal and abnormal patient, which at least consist of :
1. Traumatic : fracture and joint disclocation 2. Infection, ex. Osteomyelitis
3. Malignancy, ex. Osteosarcoma Learning Task
Find Radiologic term
o Systematicsm of x-ray reading o Radioscleerotic
o Radiolucent o Codmann Triangle o Onion Shape. o Gegraphic patern o Mooth eaten o Permeated patern Self Assessment
MODULE
7
THE APPENDICULAR SKELETON
Prof. Dr. dr. Mangku Karmaya, M.Repro
AIMS:
Establish the appendicular skeleton for human movement LEARNING OUTCOMES:
Comprehend the macroscopic aspect of appedicular skeleton CURRICULUM CONTENTS:
1. Upper 2. Lower limb ABSTRACTS
Both appendicular skeletons that build upper and lower limb have the similar patern. They attach at axial skeleton through girdle. Humeral joint is analog to hip joint, humery analog to femur, elbow joint to knee, radius ulna to tibia fibula, wrist to ankle and hand to foot. Due to work load of both appendicular skeletons, joint and lower limb muscles are stronger than upper limb. The type of joint promotes for upper limb for more free movement, pronation supination and occur inversion eversion on lower limb. The phalanges of hand can do apposition movement compare to foot is not possible. All of the appedicular skeleton were covered by group muscles, and their type are similar.
UPPER LIMB
SELF DIRECTING LEARNING
Basic knowledge that must be known:
1. The upper and lower limb. Explain the part of those bone 2. Important parts of upper and lower limb bones
3. The muscles in the regions of shoulder/buttock, fore arm/femur, lower arm/leg, hand/pedis
SCENARIO
Case 1
A15-year-old girl, while demonstrating to her friends her proficiency at standing on her hands, suddenly went off balance and put all her body weight on her left outstretched hand. A distinctive cracking noise was heard, and he felt a suddent pain in her left shoulder region. On examination in the emergency department, the smooth contour of her left
shoulder was absent. The clavicle was obviously fractured, and the edge of the bony fragments could be palpated.
Learning task
1. Which part of clavicle that the fracture commonly occurs. Why?
2. What is the position of lateral and medial fragments according to muscles traction? 3. Describe all bones that joint the clavicle.
4. What is the function of clavicle? Case 2
A 63-year-old man fell down a flight of stairs and sustained a fracture of the lower end of the left radius. On examination the distal end of the radius was displaced posteriorly. This patient has sustained a Colles’ fracture.
Learning task
1. Why the distal end of the radius was displaced posteriorly? 2. Describe all bones that joint the tradius
3. Describe all muscles attached to the radius LOWER LIMB
Case 1
After recovery from long hospitalization, a 65-year-old woman try to walk alone. But suddenly she fell down. The doctor noted that the woman had a spontaneous fracture of the neck of the femur . The neck fractures are common and are of two types, subcapital and trochanteric. Subcapital femoral neck fractures are particularly common in women after menopause.
Learning task
1. Why the fractures have gender predisposition?
2. In the neck fractures the leg become shortened and pointed laterally. Why? (Think about the muscles pull action).
3. Describe all mucles attached to the neck and shaft of the femur Case 2
A motocyclist try his new motorcycle in town mainroad in high speed. But he did not know the truck in front of him suddenly turn to the right. The accident could not be avoided. After striking hard the truck the man was thrown 10 meters and landed first on his right leg. On examination in the emergency department the doctor noted fractures of the right tibia with minimal displacement.
Learning task
1. Why the displacement was minimal?
2. Why the fracture of the shaft of the tibia are more frequent compare to fibula? 3. What muscles are attached to tibia?
Self assessment
1. Compare the upper and lower limb
2. Identify the important parts of upper and lower limb bones
MODULE
8
BONE FRACTURE
dr. Wien Aryana, SpOT
AIMS:
Establish tentative diagnosis, provide initial management and/or refer patient with: Fracture and dislocation in child and adult.
LEARNING OUTCOMES:
Establish tentative diagnosis, provide initial management and/or refer patient with: Fracture and dislocation in child and adult.
CURRICULUM CONTENTS: 1. Bone healing
2. Diagnosis, provide initial management and/or refer patient with: Fracture and dislocation in child and adult.
ABSTRACTS
A tentative diagnosis fracture is a break in the structural continuity of bone. It may be no more than a crack, a crumpling or a splintering of the cortex; more often the break is complete and the bone fragments are displaced.
Most fractures are caused by sudden and excessive force, which may be tapping, crushing, bending, twisting or pulling. The process of fracture repair varies according to the type of bone involved and the amount of movement at the fracture site.
The specific aims of fracture treatment are: to relieve pain, to obtain and maintain satisfactory position of the fracture fragment, to allow and if necessary to encourage bony union; to restore optimum function not only in the fracture limb or spine but also in the patient as a person.
There are three degrees of joint stability: occult joint instability, subluxation in which the joint surfaces have lost their normal relationship but still retain considerable contact; dislocation in which the joint surfaces have completely lost contact.
The general principles of treatment for dislocations and subluxations: in order to restore normal congruity to the joint surfaces, perfect reduction of dislocations and subluxations must be achieved, either by closed manipulation or, when necessary, by open reduction. SELF DIRECTING LEARNING
Basic knowledge that must be known:
1. The type of fracture and healing process 2. Fracture in adult and children
3. Management of fracture
SCENARIO
Male 30 years old, came to our hospital with painful, swollen on he left thigh and difficulty to move his leg after traffic accident. He was motor cyclist and hit by a car. On physical examination: shortening of his left lower leg and false movement found.
1. What symptom and sign you find?
2. Which one is the probably symptom and sign for fracture?
3. Which one is the significant (full blown) symptom and sign for fracture? Learning Task
1. How fractures happen? 2. Types of fracture
3. How fractures are displaced? 4. Fracture healing
Self Assessment
1. Describe about normal healing of fracture 2. Describe about abnormal healing of fracture LEARNING OUTCOME
Establish tentative diagnosis, provide initial management and/or refer patient with: Fracture and dislocation in child and adult.
o Fracture in adult SCENARIO
Male 25 years old, came to our hospital with painfull on he left thigh and difficulty to move his leg after traffic accident. He was motor cyclist and hit by a car.
On physical examination: shortening of his left lower leg and false movement found. 1. What is your assessment for this patient?
2. How to manage the patient? Learning Task
1. The special features of fractures and dislocation in adult and children 2. The general principles of fracture treatment
3. How to diagnosis of fracture and associated injuries Self Assessment
1. Describe the special features of fractures and dislocation in adult 2. Explain the general principles of fracture treatment
3. How to diagnosis of fracture and associated injuries 4. Describe 3 degree of joint histability
LEARNING OBJECTIVE
Establish tentative diagnosis, provide initial management and/or refer patient with: Fracture and dislocation in child and adult.
o Fracture in children
SCENARIO
Male, 3 years old, came to emergency unit with painfull on the right elbow and difficulty to movement his elbow after traffic accident. On physical examination; swelling of right elbow.
Learning Task
1. The specific methods of treatment of closed fracture
2. The complication of fractures and complication of fracture treatment 3. Explain about 3 degree of joint instability
Self Assessment
1. Describe the special features of fractures and dislocation in children 2. Explain the specific methods of treatment of closed fracture
3. Describe about the complication of fractures
4. Describe about the complication of fracture treatment
MODULE
9
BONE JOINT, TENDONS AND LIGAMENTS
Prof. Dr.dr. Mangku Karmaya, M.Repro
AIMS:
Describe normal structure and function of Joints and articular cartilage and.
LEARNING OUTCOMES:
Apply its concepts and principles in the approach of patient with common arthritis and related inflammation/ infection
CURRICULUM CONTENTS: 1. cartilage of joint
2. sinovium and sinovial fluid 3. function of Joint
ABSTRACTS
A joint is an articulation, the place of union or junction between two or more rigid components (bone, cartilages, or even parts of the same bone). Joints show variety of form and function. Some joints have no movement; others allow only slight movement, and some are freely movable.
There are three types of joint according to the manner of material by which the articulating bones are united: (1) fibrous joints are united by fibrous tissue. This type are found as syndesmosis where a sheet of fibrous tissue, either a ligament or fibrous membrane, interosseous membrane in the forearm (between radius and ulna) and gomphosis or dentoalveolar syndesmosis between the root of the tooth and the alveolar
process. (2) cartilaginous joints are united by cartilage or fibrocartilage and (3) synovial joints, the most common type of joint, that the articulating surfaces are covered with cartilage and united by a fibrous capsule.
Distinguishing features of a synovial joint are, a joint cavity, articular cartilage that cover the bone end, and articular or joint capsule (fibrous capsule lined with synovial membrane) that enclose articulating surfaces and joint cavity. There are several types of synovial joint: (1) hinge joint (uniaxial: permit flexion and extension only eg., elbow joint), (2) pivot joint (uniaxial: allow rotation, a round process of bone fits into a bony ligamentous socket e.g., atlantooccipital joint between atlas /C1 and axis/C2), (3) saddle joint (biaxial: are shape like a saddle; i.e., they are concave and convex where bones articulate); (4) condyloid joints (biaxial: permit flexion and extension, abduction and adduction, and circumduction; eg., metacarpophalangeal joints or digits); (5) plane joints permit gliding or sliding movement (e.g., acromioclavicular joint) and (6) ball and socket joints (multiaxial: permit movement in several axes: flexion-extension, abductuction-adduction, medial and lateral rotation and circumduction, where a rounded head fits into a concavity)
SELF DIRECTING LEARNING
Basic knowledge that must be known:
1. Classification of joints and its structures 2. Parts of synovial joint
3. The anatomy of ligament, tendon, aponeurosis, synovial tendon sheaths and bursae and their functions
4. Intra and extra articular ligaments SCENARIO :
Case 1
A 60 year-old-woman fell down the stairs and was admitted to the emergency department with severe right shoulder pain. On examination, the patient was sitting up with her right arm by her side and her right elbow joint supported by the left hand. Inspection of the right shoulder showed loss of the normal rounded curvature and evidence of slight swelling below the right clavicle. Any atempt at active or passive movement of the shoulder was stop by severe pain in the shoulder. A diagnosis of dislocation of he right shoulder joint was made.
Learning task
1. Why the shoulder joint prone to dislocation? 2. Why the downward dislocation more frequent?
3. Describe the shoulder joint, its movement and the muscles involved. Case 2
A father seeing his 3-year-old son playing in the garden, ran up and pick him up by both hands and swung him around in a circle. The child’s enjoyment suddenly urned to tearsand he said left elbow hurt. On examination, the child held his left elbow joint hemiflexed and his forearm pronated.
Learning task
1. What was really happen to the child’s elbow?
2. Why the elbow position hemiflexed and the fore arm pronated?
3. Describe the elbow joint (the bone, type, capsule, ligaments, synovial membrane). Case 3
flexed, the femur rotatede medially, and the leg abducted on the thigh. A sudden pain was felt in the right knee joint, and he was unable to extend it. The student was diagnosed as having a torn medial meniscus of the kenee joint.
Learning task
1. What is meniscus? What is discus (disc)? What are their differences? 2. What structures involved in forming the knee joint?
3. What kind of movement in the knee joint and what muscles involved in the movement?
4. Compare the knee joint and elbow joint. Self assessment
1. Describe the classification of joints and its structures
2. Describe the six major types of synovial joints and give examples for each type and their possible movements
3. Identify the parts of synovial joint 4. Describe the joint of vertebral column 5. Compare the joints of upper and lower limb AIMS:
Describe normal structure and function of Tendons and ligaments. LEARNING OUTCOMES:
Apply its concepts and principles in the approach of patient with musculoskeletal disorders such as tendinitis
CURRICULUM CONTENTS: 1. Tendon
2. Ligament
ABSTRACTS OF LECTURES
Structure and Function of Ligaments and Tendons
The largest structure in the above schematic is the tendon (shown) or the ligament itselt. The ligament or tendon then is split into smaller entities called fascicles. The fascicle contains the basic fibril of the ligament or tendon, and the fibroblasts, which are the biological cells that produce the ligament or tendon. There is a structural characteristic at this level that plays a significant role in the mechanics of ligaments and tendons: the crimp of the fibril. The crimp is the waviness of the fibril; we will see that this contributes significantly to the nonlinear stress strain relationship for ligaments and tendons and indeed for bascially all soft collagenous tissues.
SCENARIO Case 1
A 54-year-old man was told by his physician to reduce his weight. He was prescribed a diet and was advised to exercise more. One morning while jogging, he heard a sharp snap and felt a sudden pain in his right lower calf. Onaxamination in the emergency
department, physician noted that the upper part of the right calf was swollen and a gap was apparent between the swelling and the heel. A diagnosis of rupture of the right Achilles tendon was made.
Learning task
1. Why there was a gap apparent between the swelling and the heel? 2. Describe the anatomical and physiological aspects of Achilles tendon. Case 2
A 27-year-old woma was running across some rough ground when the stumbled and overinverted her left foot. On examination in the emergency department of the local hospital, the lateral side of the left ankle was tender and swollen. A small area of hgreat tendernes was found below and in front of the lateral m,alleolus. X-ray exmination on the ankle joint was negative. A diagnosis of sprain of the left ankle was made.
Learning task
1. Why overinverted can cause sprain on the lateral side? 2. Describe the ankle joint, the muscles and the movements. 3. What structures as a stabilisator of ankle joint?
Case 3
Learing task
1. What tendon supposed to be injured? Why?
2. Describe the elbow joint, its movements and its muscles. Self assessment
1. Describe the differences between ligament, tendon, aponeurosis, synovial tendon sheaths and bursae and their functions
2. Describe the intra and extra articular ligaments
3. Describe some clinical aspects of the ligaments, tendon, aponeurosis, synovial tendon sheath and bursae.
MODULE
10
BONE AND IMUNOLOGY DISORDERS
(OSTEOARTHRITIS AND GOUT ARTHRITIS)
Prof. Dr. dr. Tjok Raka Putra, Sp.PD
AIMS:
Establish tentative diagnosis, provide initial management and/or refer patient with imunologis disorder.
LEARNING OUTCOMES:
Establish tentative diagnosis, provide initial management and/or refer patient with osteoarthritis
CURRICULUM CONTENTS: 1. Osteoarthritis
