Structure of bone Bone is composed partly of ?brous tissue, partly of bone matrix comprising phosphate and carbonate of lime, intimately mixed together. The bones of a child are about two-thirds ?brous tissue, whilst those of the aged contain one-third; the toughness of the former and the brittleness of the latter are therefore evident.
The shafts of the limb bones are composed of dense bone, the bone being a hard tube surrounded by a membrane (the periosteum) and enclosing a fatty substance (the BONE MARROW); and of cancellous bone, which forms the short bones and the ends of long bones, in which a ?ne lace-work of bone ?lls up the whole interior, enclosing marrow in its meshes. The marrow of the smaller bones is of great importance. It is red in colour, and in it red blood corpuscles are formed. Even the densest bone is tunnelled by ?ne canals (Haversian canals) in which run small blood vessels, nerves and lymphatics, for the maintenance and repair of the bone. Around these Haversian canals the bone is arranged in circular plates called lamellae, the lamellae being separated from one another by clefts, known as lacunae, in which single bone-cells are contained. Even the lamellae are pierced by ?ne tubes known as canaliculi lodging processes of these cells. Each lamella is composed of very ?ne interlacing ?bres.
GROWTH OF BONES Bones grow in thickness from the ?brous tissue and lime salts laid down by cells in their substance. The long bones grow in length from a plate of cartilage (epiphyseal cartilage) which runs across the bone about 1·5 cm or more from its ends, and which on one surface is also constantly forming bone until the bone ceases to lengthen at about the age of 16 or 18. Epiphyseal injury in children may lead to diminished growth of the limb.
REPAIR OF BONE is e?ected by cells of microscopic size, some called osteoblasts, elaborating the materials brought by the blood and laying down strands of ?brous tissue, between which bone earth is later deposited; while other cells, known as osteoclasts, dissolve and break up dead or damaged bone. When a fracture has occurred, and the broken ends have been brought into contact, these are surrounded by a mass of blood at ?rst; this is partly absorbed and partly organised by these cells, ?rst into ?brous tissue and later into bone. The mass surrounding the fractured ends is called the callus, and for some months it forms a distinct thickening which is gradually smoothed away, leaving the bone as before the fracture. If the ends have not been brought accurately into contact, a permanent thickening results.
VARIETIES OF BONES Apart from the structural varieties, bones fall into four classes: (a) long bones like those of the limbs; (b) short bones composed of cancellous tissue, like those of the wrist and the ankle; (c) ?at bones like those of the skull; (d) irregular bones like those of the face or the vertebrae of the spinal column (backbone).
The skeleton consists of more than 200 bones. It is divided into an axial part, comprising the skull, the vertebral column, the ribs with their cartilages, and the breastbone; and an appendicular portion comprising the four limbs. The hyoid bone in the neck, together with the cartilages protecting the larynx and windpipe, may be described as the visceral skeleton.
AXIAL SKELETON The skull consists of the cranium, which has eight bones, viz. occipital, two parietal, two temporal, one frontal, ethmoid, and sphenoid; and of the face, which has 14 bones, viz. two maxillae or upper jaw-bones, one mandible or lower jaw-bone, two malar or cheek bones, two nasal, two lacrimal, two turbinal, two palate bones, and one vomer bone. (For further details, see SKULL.) The vertebral column consists of seven vertebrae in the cervical or neck region, 12 dorsal vertebrae, ?ve vertebrae in the lumbar or loin region, the sacrum or sacral bone (a mass formed of ?ve vertebrae fused together and forming the back part of the pelvis, which is closed at the sides by the haunch-bones), and ?nally the coccyx (four small vertebrae representing the tail of lower animals). The vertebral column has four curves: the ?rst forwards in the neck, the second backwards in the dorsal region, the third forwards in the loins, and the lowest, involving the sacrum and coccyx, backwards. These are associated with the erect attitude, develop after a child learns to walk, and have the e?ect of diminishing jars and shocks before these reach internal organs. This is aided still further by discs of cartilage placed between each pair of vertebrae. Each vertebra has a solid part, the body in front, and behind this a ring of bone, the series of rings one above another forming a bony canal up which runs the spinal cord to pass through an opening in the skull at the upper end of the canal and there join the brain. (For further details, see SPINAL COLUMN.) The ribs – 12 in number, on each side – are attached behind to the 12 dorsal vertebrae, while in front they end a few inches away from the breastbone, but are continued forwards by cartilages. Of these the upper seven reach the breastbone, these ribs being called true ribs; the next three are joined each to the cartilage above it, while the last two have their ends free and are called ?oating ribs. The breastbone, or sternum, is shaped something like a short sword, about 15 cm (6 inches) long, and rather over 2·5 cm (1 inch) wide.
APPENDICULAR SKELETON The upper limb consists of the shoulder region and three segments – the upper arm, the forearm, and the wrist with the hand, separated from each other by joints. In the shoulder lie the clavicle or collar-bone (which is immediately beneath the skin, and forms a prominent object on the front of the neck), and the scapula or shoulder-blade behind the chest. In the upper arm is a single bone, the humerus. In the forearm are two bones, the radius and ulna; the radius, in the movements of alternately turning the hand palm up and back up (called supination and pronation respectively), rotating around the ulna, which remains ?xed. In the carpus or wrist are eight small bones: the scaphoid, lunate, triquetral, pisiform, trapezium, trapezoid, capitate and hamate. In the hand proper are ?ve bones called metacarpals, upon which are set the four ?ngers, each containing the three bones known as phalanges, and the thumb with two phalanges.
The lower limb consists similarly of the region of the hip-bone and three segments – the thigh, the leg and the foot. The hip-bone is a large ?at bone made up of three – the ilium, the ischium and the pubis – fused together, and forms the side of the pelvis or basin which encloses some of the abdominal organs. The thigh contains the femur, and the leg contains two bones – the tibia and ?bula. In the tarsus are seven bones: the talus (which forms part of the ankle joint); the calcaneus or heel-bone; the navicular; the lateral, intermediate and medial cuneiforms; and the cuboid. These bones are so shaped as to form a distinct arch in the foot both from before back and from side to side. Finally, as in the hand, there are ?ve metatarsals and 14 phalanges, of which the great toe has two, the other toes three each.
Besides these named bones there are others sometimes found in sinews, called sesamoid bones, while the numbers of the regular bones may be increased by extra ribs or diminished by the fusion together of two or more bones.... bone
The presentation of dystonia may be focal (usually in adults) causing blepharospasm (forceful eye closure), oromandibular dystonia (spasms of the tongue and jaw), cranial dystonia/Meige syndrome/Brueghel’s syndrome (eyes and jaw both involved), spastic or spasmodic dysphonia/laryngeal dystonia (strained or whispering speech), spasmodic dysphagia (di?culty swallowing), spasmodic torti/latero/ ante/retrocollis (rotation, sideways, forward or backward tilting of the neck), dystonic writer’s cramp or axial dystonia (spasms deviating the torso). Foot dystonia occurs almost exclusively in children and adolescents. In adults, the condition usually remains focal or involves at most an adjacent body part. In children, it may spread to become generalised. The condition has always been considered rare, but commonly is either not diagnosed or mistakenly thought to be of psychological origin. It may, in fact, be half as common as MULTIPLE SCLEROSIS (MS). Similar features can occur in some subjects treated with major tranquillising drugs, in whom a predisposition to develop dystonia may be present.
One rare form, called dopa-responsive dystonia, can be largely abolished by treatment with LEVODOPA. Particularly in paediatric practice this drug will often be tried on a child with dystonia.... dystonia
Patients often have a poor sleep pattern, waking exhausted. Unexplained headache, urinary frequency and abdominal symptoms are common, but no cause has been found. Patients generally score highly on measures of anxiety and DEPRESSION. Fibromyalgia is not an ideal description; idiopathic di?use-pain syndrome and non-restorative sleep disorder are increasingly preferred terms.
Clinical ?ndings are generally unremarkable; most important is the presence of multiple hyperalgesic tender sites (e.g. low cervical spine, low lumbar spine, suboccipital muscle, mid upper trapezius, tennis-elbow sites, upper outer quadrants of buttocks, medial fat pad of knees). In ?bromyalgia, hyperalgesia (excessive discomfort) is widespread and symmetrical, but absent at sites normally non-tender. Claims by patients to be tender all over are more likely to be due to fabrication or psychiatric disturbance. OSTEOARTHRITIS and periarticular syndrome are much more common and should be excluded, together with other conditions, such as hypothyroidism (see THYROID GLAND, DISEASES OF), SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) and in?ammatory myopathy (see MUSCLES, DISORDERS OF), which may present with similar symptoms.
Cause There is no investigational evidence of in?ammatory, metabolic or structural abnormality, and the problem seems functional rather than pathological. SEROTONIN de?ciency has a signi?cant role in ?bromyalgia syndrome.
Management Controlled trials have con?rmed the usefulness of low-dose AMITRIPTYLINE or DOTHIEPIN together with a graded exercise programme to increase aerobic ?tness. How this works is still unclear; its e?cacy may be due to its normalising effects on the sleep centre or ‘pain gating’ (reduction of pain sensation) at the spinal-cord level. Prognosis is often poor. Nevertheless, suitable advice and training can help most patients to learn to cope better with their condition and avoid unnecessary investigations and drug treatments.... fibromyalgia syndrome
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