THE SKELETAL

SYSTEM:

BONE TISSUE
Dr. Henry Pebruanto, SpOT
CURICULUM VITAE

EDUCATION UNDER-POST GRADUATE TRAININGS

⦿ Medical Faculty of Udayana University, Denpasar – Bali; 2005
⦿ Orthopaedic Training (Airlangga Univ., Sby/ Udayana Univ., Dps); Jan 12
⦿ Overseas Observership Programme (Hip and Knee Arthroplasty): Perth – WA; Nov 10
⦿ ASEAN Cadaveric Knee Course: Chiang Mai Univ. – Thailand; Apr 12.
⦿ Australian Educational Program (Knee &Shoulder): Sydney – NSW; Jun 12
⦿ ASEAN Cadaveric Knee Course: Bangkok – Thailand; May 14.
⦿ ASEAN EASE (Express Arthroplasty and Arthroscopy Skills Education) Knee Course :
Bangalore – India; May 15.

COURSES
⦿ Advanced Trauma Life Support (Denpasar – Bali); Jan 06
⦿ Basic Orthopedic Skill Course (Surabaya – East Java); Aug 07
⦿ Basic Surgical Skills Course (Surabaya – East Java); Jan 08
⦿ Ultrasonography for Abdominal and Chest Trauma Course (Jakarta); Apr 08
⦿ Total Nutritional Treatment Course (Tanah Lot – Bali); Dec 08
⦿ Basic AO Trauma Course (Nusa Dua – Bali); May 09
⦿ Bali Hand Course (Denpasar – Bali); Jul 09
⦿ Post Graduate Course : Musculoskeletal Trauma (Jakarta); Nov 09
⦿ 8th Annual Meeting of Indonesian Spine Society & 1st International Society for Minimal
Intervention in Spinal Surgery (Denpasar – Bali); Jun 10
COURSES
⦿ Workshop Hemiarthroplasty and Bone Substitute (Malang – East Java); Jun 10
⦿ Ponsetti Course (Denpasar – Bali); Dec 10
⦿ 4th Arthroplasty Workshop : Jump Start on Total Knee Replacement (Jakarta); Apr 11
⦿ 3rd Arthroplasty Workshop : Jump Start on Total Hip Replacement (Jakarta); Apr 11
⦿ AO Spine Principles Course (Jakarta); Jun 11
⦿ Current Diagnosis and Comprehensive Treatment of Brachial Plexus Injury (Surabaya
– East Java); Oct 11
⦿ 3rd Pelvic and Acetabular Course and Workshop (Surabaya – East Java); Oct 11
⦿ Lower Extremity Trauma Course (Denpasar – Bali); Jan 12
Bone Tissue & Homeostasis
⦿ Bone tissue ~ continuously growing,
remodeling, and repairing itself.

⦿ Homeostasis of the body by

● providing support and protection,
● producing blood cells, and
● storing minerals and triglycerides.
Bone Tissue & Homeostasis
⦿ Each individual bone is considered an organ
● composed of several different :
○ bone or osseous tissue,
○ cartilage,
○ dense connective tissue,
○ epithelium, adipose tissue, and
○ nervous tissue.
⦿ Bone tissue
● a complex and dynamic living tissue
● continually engages in a process called remodeling
(the construction of new bone tissue & breaking down of
old bone tissue).
⦿ The entire framework of bones and their cartilages,
along with ligaments and tendons, constitutes the
skeletal system.
Functions of Bone & Skeletal System
⦿ Support
⦿ Protection
⦿ Assistance in movement
⦿ Mineral homeostasis (storage and
release)
⦿ Blood cell production
⦿ Triglyceride storage
Functions of Bone & Skeletal System
⦿ Support
● supporting soft tissues and
● providing attachment points for the
tendons of most skeletal muscles.
Functions of Bone & Skeletal System
⦿ Protection
● protects the most important internal organs
from injury.
● For example,
○ cranial bones protect the brain,
○ the rib cage protects the heart and lungs.
Functions of Bone & Skeletal System
⦿ Assistance in movement
● Most skeletal muscles attach to bones;
● when they contract, they pull on bones to
produce movement.
Functions of Bone & Skeletal System
⦿ Mineral homeostasis (storage & release)
● Bone tissue ~ 18% BW.
● It stores several minerals, especially calcium
and phosphorus, which contribute to the
strength of bone.
● Bone tissue stores ~ 99% of the body’s
calcium.
● On demand, bone releases minerals into the
blood to maintain critical mineral balances
(homeostasis) and to distribute the minerals
to other parts of the body.
Functions of Bone & Skeletal System
⦿ Blood cell production
● red bone marrow produces RBCs, WBCs,
and PLTs ~ a process called hemopoiesis.

○ In a newborn, all bone marrow is red.

○ With increasing age, much of the bone marrow

changes from red to yellow
Functions of Bone & Skeletal System
⦿ Triglyceride storage
● Yellow bone marrow consists mainly of
adipose cells, which store triglycerides.
● The stored triglycerides are a potential
chemical energy reserve
Anatomy Human Body : Skeletal
Anatomy Human Body : Skeletal
Anatomy Human Body : Skeletal
Anatomy Human Body : Skeletal
Anatomy Human Body : Skeletal
Anatomy Human Body : Skeletal
Anatomy Human Body : Skeletal
Anatomy Human Body : Skeletal
Anatomy Human Body : Skeletal
Anatomy Human Body : Skeletal
Anatomy Human Body : Skeletal
Anatomy Human Body : Skeletal
Anatomy Human Body : Skeletal
Anatomy Human Body : Skeletal
Anatomy Human Body : Skeletal
Anatomy Human Body : Skeletal
Anatomy Human Body : Skeletal
Anatomy Human Body : Skeletal
Anatomy Human Body : Skeletal
Anatomy Human Body : Skeletal
Structure of Bone
⦿ Macroscopic bone structure may be
analyzed by considering the parts of a
long bone, such as the humerus
Structure of Bone
Histology of Bone Tissue
Bone Formation
⦿ The process by which bone forms is called
ossification or osteogenesis.
⦿ Bone formation occurs in four principal
situations :
● The initial formation of bones in an embryo and fetus,
● The growth of bones during infancy, childhood, and
adolescence until their adult sizes are reached,
● The remodeling of bone (replacement of old bone by new
bone tissue throughout life), and
● The repair of fractures (breaks in bones) throughout life.
Bone Formation
⦿ Initial Bone Formation in an Embryo and
Fetus
● initially composed of mesenchyme in the
general shape of bones, is the site where
cartilage formation and ossification occur
during the sixth week of embryonic
development.
○ intramembranous ossification
○ endochondral ossification
Bone Formation
⦿ Initial Bone Formation in an Embryo and
Fetus
○ Intramembranous Ossification
Bone Formation
⦿ Initial Bone Formation in an Embryo and
Fetus
○ endochondral ossification
Bone Formation
⦿ Initial Bone Formation in an Embryo and
Fetus
○ endochondral ossification
Bone Formation
⦿ Bone Growth during Infancy, Childhood,
and Adolescence
● Growth in Length
○ interstitial growth of cartilage on the epiphyseal
side of the epiphyseal plate and
○ replacement of cartilage on the diaphyseal side
of the epiphyseal plate with bone by endochondral
ossification.
Bone Formation
⦿ Bone Growth during Infancy, Childhood,
and Adolescence
● Growth in Length
○ epiphyseal (growth) plate
● Zone of resting cartilage
● Zone of proliferating cartilage
● Zone of hypertrophic cartilage
● Zone of calcified cartilage
Bone Formation
⦿ Bone Growth during Infancy, Childhood,
and Adolescence
● Growth in Length
○ epiphyseal (growth) plate
Bone Formation
Epiphyseal (Growth) Plate
Bone Formation
Epiphyseal (Growth) Plate
Bone Formation
Epiphyseal (Growth) Plate
Bone Formation
Epiphyseal (Growth) Plate
Bone Formation
Epiphyseal (Growth) Plate
Bone Formation
⦿ Bone Growth during Infancy, Childhood,
and Adolescence
● Growth in Thickness
○ only by appositional growth
Bone Formation
⦿ Bone Growth during Infancy, Childhood,
and Adolescence
● Growth in Thickness
○ only by appositional growth
Bone Formation
⦿ Bone Growth during Infancy, Childhood,
and Adolescence
● Growth in Thickness
○ only by appositional growth
Bone Formation
⦿ Remodeling of Bone
● Bone remodeling is the ongoing replacement
of old bone tissue by new bone tissue.

○ bone resorption, the removal of minerals and

collagen fibers from bone by osteoclasts,
● destruction of bone extracellular matrix.
○ bone deposition, the addition of minerals and
collagen fibers to bone by osteoblasts.
● formation of bone extracellular matrix.
Bone Formation
⦿ Remodeling of Bone
● renewal rate for
○ compact bone tissue ~ 4% per year
○ spongy bone tissue ~ 20% per year
● different rates in different regions.
● remodeling also removes injured bone,
replacing it with new bone tissue.
● may be triggered by factors such as exercise,
sedentary lifestyle, and changes in diet.
Bone Formation
⦿ Remodeling of Bone
● Remodeling has several other benefits
○ the strength of bone is related to the degree to
which it is stressed,

● if newly formed bone is subjected to heavy loads, it will

grow thicker ! stronger than the old bone.

● the shape of a bone ~ stress patterns experienced during

the remodeling process.

● new bone is more resistant to fracture than old bone.

 Bone Formation
⦿ Remodeling of Bone
○ An osteoclast attaches tightly to the bone surface at the endosteum or
periosteum and forms a leakproof seal at the edges of its ruffled border.
○ Then it releases protein-digesting lysosomal enzymes and several
acids into the sealed pocket.
○ The enzymes digest collagen fibers and other organic substances
while the acids dissolve the bone minerals.
○ Several osteoclasts carve out a small tunnel in the old bone.
○ The degraded bone proteins and extracellular matrix minerals,
mainly calcium and phosphorus, enter an osteoclast by endocytosis,
cross the cell in vesicles, and undergo exocytosis on the side opposite
the ruffled border.
○ The products of bone resorption diffuse into nearby blood capillaries.
○ Once a small area of bone has been resorbed, osteoclasts depart
and osteoblasts move in to rebuild the bone in that area.
 Bone Formation
⦿ Factors Affecting Bone Growth and Bone
Remodeling
● Adequate dietary intake of minerals and vitamins
○ Minerals
● Large amounts of Ca and P
● Smaller amounts of magnesium, fluoride, and manganese
○ Vitamins
● Vitamin A ~ stimulates activity of osteoblasts.
● Vitamin C ~ synthesis of collagen
● Vitamin D ~ increasing the absorption of Ca in the GIT.
● Vitamins K and B12 ~ synthesis of bone proteins.
○ Hormones
● Insulinlike growth factors (IGFs) (most important during childhood), produced by
liver & bone tissue.
- IGFs ~ produced in response to the secretion of human growth hormone (hGH)
from the anterior lobe of the pituitary gland.
● Thyroid hormones (T3 and T4) ~ stimulating osteoblasts.
● Insulin from the pancreas ~ increasing the synthesis of bone proteins.
 Bone Formation
⦿ Factors Affecting Bone Growth and Bone Remodeling
● At puberty, the secretion of sex hormones causes a dramatic effect on bone
growth.
○ estrogens (produced by the ovaries) and
○ androgens such as testosterone (produced by the testes).
● Females ~ higher levels of estrogens ; low levels of androgens.
● Males ~ higher levels of androgens; low levels of estrogens.

● Adrenal glands of both sexes produce androgens, and

● Adipose tissue, can convert androgens to estrogens.

● Responsible for
○ increased osteoblast activity,
○ synthesis of bone extracellular matrix, and
○ the sudden “growth spurt”.

● Estrogens ~ promote changes in the skeleton that are typical of females,

such as widening of the pelvis.
 Bone Formation
⦿ Factors Affecting Bone Growth and Bone Remodeling
● Sex hormones (especially estrogens), shut down growth at epiphyseal
(growth) plates, causing elongation of the bones to cease.
● Bone growth (length) typically ends earlier in female ~ due to higher
levels of estrogens.

● Adulthood, sex hormones contribute to bone remodeling

○ slowing resorption of old bone
● ~ promoting apoptosis (programmed death) of osteoclasts.
○ promoting deposition of new bone.

● Moderate weight-bearing exercises

○ maintain sufficient strain on bones to increase and
○ maintain their density.
Fracture and Repair of Bone
⦿ A fracture ~ any break in a bone.
● Fractures are named according to their severity, the
shape or position of the fracture line.
⦿ A bone may fracture without visibly breaking.
● Ex. Stress fracture.
○ Result from repeated, strenuous activities (running,
jumping, or aerobic dancing).
○ Also result from disease processes (osteoporosis)
○ About 25% of stress fractures involve the tibia.
○ Standard x-ray ~ fail to reveal the presence of stress
fractures, they show up clearly in a bone scan.
Fracture and Repair of Bone
⦿ The repair of a bone fracture involves the
following phases :
● Reactive phase
● Reparative phase : Fibrocartilaginous callus
formation
● Reparative phase : Bony callus formation
● Bone remodeling phase
Fracture and Repair of Bone
Fracture and Repair of Bone
⦿ Reactive phase
● Early inflammatory phase.
● Fracture hematoma formation (6 to 8 hours after
the injury).
● Nearby bone cells die.
● Swelling and inflammation occur in response to
dead bone cells
● Osteoclasts begin to remove the dead or damaged
tissue in and around the fracture hematoma.
● Up to several weeks.
Fracture and Repair of Bone
⦿ Reparative phase : Fibrocartilaginous callus
formation
● The formation of a fibrocartilaginous callus and a bony
callus to bridge the gap between the broken ends of
the bones.
● Blood vessels grow into the fracture hematoma and
phagocytes begin to clean up dead bone cells.
● Fibroblasts from the periosteum invade the fracture
site and produce collagen fibers.
● Cells from the periosteum develop into chondroblasts
and begin to produce fibrocartilage.
● ! development of a fibrocartilaginous (soft) callus.
● Takes about 3 weeks.
Fracture and Repair of Bone
⦿ Reparative phase : Bony callus formation
● Osteoprogenitor cells develop into osteoblasts,
which begin to produce spongy bone trabeculae.
● The trabeculae join living and dead portions of the
original bone fragments.
● Fibrocartilage is converted to spongy bone, and
the callus is then referred to as a bony (hard)
callus.
● The bony callus lasts about 3 to 4 months.
Fracture and Repair of Bone
⦿ Bone remodeling phase
● The final phase ~ remodeling of the callus.
● Dead portions of the original fragments of broken
bone are gradually resorbed by osteoclasts.
● Compact bone replaces spongy bone around the
periphery of the fracture.
● Fracture line is undetectable, even in a
radiograph (x-ray).
● A thickened area on the surface of the bone
remains as evidence of a healed fracture.
Bone’s Role in
Calcium

Homeostasis
Exercise and Bone Tissue
⦿ Bone ~ has the ability to alter its strength in
response to changes in mechanical stress.
● Under stress, bone ~ becomes stronger
○ (increased deposition of mineral salts and production of
collagen fibers by osteoblasts).
● Without mechanical stress
○ bone resorption ~ more quickly than bone formation.
⦿ Research :
● High-impact intermittent strains more strongly
influence bone deposition as compared with lower
impact constant strains.
● Running and jumping stimulate bone remodeling more
dramatically than walking.
 Exercise and Bone Tissue
⦿ The main mechanical stresses on
● pull of skeletal muscles and
● the pull of gravity.

● Bedridden or has a fractured bone in a cast, the strength

of the unstressed bones diminishes
○ loss of bone minerals and
○ decreased numbers of collagen fibers.
● Astronauts
○ subjected to the microgravity of space ~ lose bone mass.
● Bone loss ~ 1% per week.
 Exercise and Bone Tissue
⦿ Athletes ~ thicker and stronger than astronauts or
nonathletes.

⦿ Weightbearing activities (walking or moderate weight lifting),

help build and retain bone mass.

⦿ Adolescents and young adults ~ regular weight-bearing

exercise prior to the closure of the epiphyseal plates to
help build total mass.

⦿ People of all ages ~ weight-bearing exercise.

Aging and Bone Tissue
⦿ Birth – adolescence : bone production > bone
resorption.

⦿ Young adults : bone production = bone resorption.

⦿ Middle age : bone production < bone resorption !

decrease in bone mass.

⦿ Old age : bone production << bone.

● Because women’s bones ~ smaller and less massive !
loss of bone mass in old age typically has a greater
adverse effect in females.
● ~ higher incidence of osteoporosis in females.
Aging and Bone Tissue
⦿ There are two principal effects of aging on bone
tissue:
● loss of bone mass and brittleness.

● Loss of bone mass results from demineralization (the loss

of calcium and other minerals from bone extracellular
matrix).
○ > age 30 in females, accelerates greatly around age 45.
○ age 70 ~ 30% of the calcium in bones is lost.
○ ~ 8% of bone mass is lost every 10 years.

○ Males ~ calcium loss > age 60,

○ ~ 3% of bone mass is lost every 10 years.

● The loss of calcium from bones is one of the problems in

osteoporosis
Aging and Bone Tissue
⦿ There are two principal effects of aging on bone
tissue:
● loss of bone mass and brittleness.

● Brittleness results from a decreased rate of protein synthesis.

○ Organic part of bone extracellular matrix, mainly collagen fibers, gives
bone its tensile strength.
○ The loss of tensile strength ~ very brittle and susceptible to fracture.

● In elderly ~ collagen fiber synthesis slows ( < human growth

hormone).
○ increasing the susceptibility to fractures and loss of bone mass ! deformity,
pain, loss of height, and loss of teeth.
THANK YOU