Shifa College of Medicine
LOCOMOTOR SYSTEM (LMS)
MODULE
STUDENT’S STUDY GUIDE
Class of 2016
Jan. 30-March 22, 2012
1
Module:
Locomotor system
Year:
1
Spiral:
1
Block:
II
Duration:
8 weeks
Course Director:
Dr. Ashraf Hussain
Facilitating Departments: Anatomy, Physiology, Biochemistry,
Surgery, Medicine, Radiology, Skills
Lab, SIH Rehabilitation
2
CONTENTS
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Page
Introduction to the Locomotor Module
How To Use This Guide
Aims
Overview of LMS Themes
Learning Methodology
Assessment Methods
Recommended Textbooks
Study Tips
Themes objectives, cases & Vignettes
Glossary
3
4
5
6
7
8
15
16
18
19-69
7o-73
Introduction to the Locomotor
On behalf of the module team I welcome you to the
Locomotor Module!
Name of this module may sound a bit difficult to you but don’t
worry, as the word “Locomotion” implies, we will have an
excursion down the path of knowledge. Initially, due to new
terminologies, you may feel overwhelmed, but still worry not.
Once you learn these terminologies, you will start conversing
fluently in the same language. For your convenience, we have
included a glossary of difficult terminologies at the end of this
guide.
The musculoskeletal system provides locomotion, support and
protection
to
the
human
body.
This
system
consists
of
osteology (the study of bones), arthrology (the study of joints),
and myology (the study of muscles).
This module is designed to include clinical case scenarios,
vignettes and SCIL Lab sessions to provide you an integrated
approach to the learning of the structure and function of the
body
and
appreciation
of
the
features,
diagnosis
and
management of common clinical conditions affecting muscles,
bones and joints. We have tried our best to create relevance of
information through incorporation of clinical cases. This will
help you when you will be doing Rheumatology module in spiral
3. A visit to Shifa Hospital Rehabilitation Center has also been
arranged to provide you with an opportunity to understand
common disabilities and rehabilitative processes.
4
How to use this guide
Read the guide carefully at least once to give you an idea of the
format of the module. The “Learning Objectives" should prove
critical in assisting you to define the areas that need to be
covered. Detailed learning objectives of each session will be
given to you at the beginning of each week, which will serve as
a blueprint to the session, but do not limit yourself to those
topics only.
Look at the session titles and the learning
objectives prior to attending them. This will give you a better
focus of the area that will be discussed in the upcoming small
or
large
group
discussion.
Remember,
always
do
some
preparatory readings before you come to the class. You are
required to put a lot effort on self directed learning. Our
ultimate aim is to guide you towards becoming a lifelong
learner.
5
Aims
The aims of this module are:
1)
To facilitate students in the process of acquiring basic
structural,
biochemical
and
functional
knowledge
pertaining to locomotor system.
2)
To impart the skill of history taking and
examination in the context of locomotor system
3)
To inculcate the habit of critical thinking, analysis,
synthesis and knowledge application by using contextual
case scenarios/vignettes
4)
To create awareness about the ethical, social and
preventive aspect of health care in the context of
locomotor system
6
physical
LMS THEMES
1) Skeletal Support & Body movements0
05%
2) Growth & Development of the Musculoskeletal system 05%
3) Muscle Weakness
25%
4) Painful Joint/Joints
10%
5) Painful Swollen Limb
10%
6) Biomechanics of Limb Joints
05%
7) Trauma nerve/vessels Injuries
15%
8) Gait/Limp
05%
9) Low Back Pain
05%
11) Ambivalence about Sports
10%
12) Stiff Neck
05%
7
Learning Modalities
The content of this module will be delivered by a combination
of different teaching strategies. These include small group
discussions (SGD), large group interactive sessions (LGIS)
problem based learning (PBL), journal club and practical
sessions in dissection hall and laboratories. A significant
proportion of your time will be spent working in small groups.
We assume that MBBS Students are adult learners and hence
spoon feeding will be avoided during the module. Instead,
facilitators will only guide you toward your learning objectives,
understanding and achieving them will be your responsibility.
Handouts and other related reference material will be provided
to you where necessary.
Remember, all this effort must be
supplemented by self-directed learning to make sure that you
have a clear understanding of the module objectives. As a
strategy, surprise quizzes and intermittent short practical
(‘spotter’) tests will be held on material covered.
Two PBL cases are also part of LMS module. These cases will be
given to you before the session.
Problem Based Learning (PBL)
Since PBL forms an important component of teaching strategy
in this module, a brief description of PBL and how it is
conducted is given below:
Problem based learning is the most significant innovation in
medical education in the past 50 years. In this modality,
8
students integrate information from several content areas. This
educational strategy promotes higher-order thinking and group
functioning skills. In LMS module, two PBL cases are included
to achieve the above mentioned objectives. These cases will be
given to you on the day of PBL session. A brief description of
how the PBL sessions are run is given below.
LEARNERS’ RESPONSIBILITIES IN PBL
Problem-based learning is a learner-centered process and it is
the responsibility of the individual learner to participate fully,
not only for his or her own learning, but also to aid the learning
of others in the group. Although much time is spent alone in
the library or at the computer, the full benefits of PBL cannot
be realized in isolation.
Each of the PBL sessions has three main parts:
1. Problem identification
2. Self study
3. Problem resolution
In the first part, a problem is broken down and possible
solutions are provided based on prior knowledge. Knowledge
gaps are identified and learning objectives determined. This
takes one hour.
The second part is away from the class room setting. The
learner will be given one or two days for addressing the
learning objectives identified by the group during the first part.
In the third session, the final solution will be constructed by
sharing information learnt. This should take one hour. The
9
second hour of this session is spent on reading up a new
problem.
ROLES OF LEARNERS DURING PBL SESSIONS
During every PBL session, a learner assumes the role of a
group leader, a scribe or a group member.
ROLE OF A GROUP LEADER

Keeps the group on track

Ensures that the 7 jump process is followed

Ensures that the deadlines are met

Helps in refining the problem statement

Makes certain that each member of the group understands
his or her role and responsibilities

Ensures everybody’s participation

Helps generate possible solutions

Helps diffuse group conflict

Makes sure that rules are followed not in a dictatorial
manner but by taking everyone along
ROLE OF A SCRIBE

Summarizes group discussions/decisions taking place during
various PBL steps

Writes everything that is being said on the white board/flip
chart


Organizes information on the white board/flip chart
Summarizes and clarifies
ROLE OF A GROUP MEMBER
10

Actively participates in the process of learning

Shares information

Assists in the maintenance of group dynamics

Follows the 7 jump process

Thoroughly reads the literature provided

Identifies gaps in one’s knowledge

Searches for information from various sources

Clarifies & summarizes

Helps in resolving conflicts

Reflects on group dynamics

Reflects on learning that is taking place individually and in
group

Provides feedback

Assists in the establishment of rules for group dynamics

Follows established rules

Be regular and punctual
Seven steps of PBL:
1. The Chair and the group read the problem; the Chair will ask
if any of the group do not understand any of the vocabulary
in the problem - not concepts or theories but literally the
vocabulary. Any queries can be resolved through the use of a
dictionary!
2. The Chair asks the group to identify what they think the
problem statement is about. At this stage, students may be
clueless about the depth of the knowledge inherent in the
statement but this will become clearer as the process
11
continues. Some of the answers therefore may be naïve or
ignorant but this does not matter. The educator must resist
the temptation at this point of stepping in and offering any
form of knowledge transmission!
3. A brainstorm session is held to ascertain what, if anything, is
known (or is believed to be known) about the subject matter
by any of the students at this point in time.
4. The Minutes Secretary identifies the key issues that have
been discussed. The Chair ensures that a clear list of what is
known, what is unclear and what needs to be investigated in
more detail is established. This is designed to help the group
understand the issues surrounding the problem.
5. The group agrees on their learning objectives and the tasks
that they will have to carry out before the next meeting.
6. Individual Study - members of the group collect the
information identified in step 5. There is a choice of two
routes here - either each student should tackle his or her
own learning objectives, or each student covers all the
learning objectives. The latter is more time consuming and
may be off-putting for students and avoid inculcating the
collaborative team based learning experience. The group
meets for the second time. The Chair asks the Minutes
Secretary to read out the learning objectives and each
student has the opportunity to present their research to the
rest of the group. It is suggested that this can be done either
formally, i.e. in turn, or through group discussion.
7. The group meets for the second time. The Chair asks the
Minutes Secretary to read out the learning objectives and
each student has the opportunity to present their research
12
to the rest of the group. It is suggested that this can be done
either formally, i.e. in turn, or through group discussion.
13
Remedial Sessions:
Remedial tutorials or other aids to learning may be possible but
if you do not tell us we will not know you have a problem. You
can contact us personally or by e-mail:
ashrafhussain9@gmail.com
Your
participation
and
performance
in
SGDs/
Demonstrations/LGIS is important and will be continuously
monitored.
This
will
be
used
in
assessing
your
overall
performance at the end of the year.
Discipline:
In the class rooms, dissection hall and laboratories you are
required to wear a plain white coat, without accessories. Edible
items and photography are not allowed inside the Dissection
Hall.
14
Assessment
In this eight weeks duration module, you will have surprise
quizzes and intermittent short spotter tests. A full-fledged
formative assessment compromising of both MCQs and IPE will
be taken in the 5th week. This will give you an idea about the
format of the examination that you will go through at the end
of the module. Of course, this will be followed by feedback on
your performance in the exam.
Comprehensive end of module exam will comprise of:
MCQ paper
80 %
SAQ paper
20 %
IPE
100 %
Marks obtained in the end of module examination and your
SGDs
evaluation
will
contribute
toward
30%
of
internal
assessment marks for final Professional Examination. In Shifa
College of Medicine, passing marks are considered to be 60%.
Evaluation
The Medical Education Department is particularly interested in
finding out the views of students on their experience in each
module. Focused group interview of the students will be
conducted in the middle and at the end of module. If thought
necessary, course evaluation forms can also be given to you
near the end of the module. We would appreciate a few
minutes of your time to fill in this form, as feedback will be
used
to
assist
in
maintaining
modules.
15
and
improving
the
future
Recommended textbooks
Which book should I study?
This is the most frequently asked question in every module.
You can find dozens of medical textbooks in the shops, most of
them are pretty good!
Selecting a textbook is like selecting a car. All cars take you
where you want to go but different features have appeal to
different people. In case of books, it can be the writing style,
diagrams and content information. Cost can be an issue for
some students but not for others. Some text books we may like
as teachers, but you may not find them “user friendly”. In this
regard, the best advice is to read through a selection of
textbooks and see which suits your style of learning. Talk to
fellow students, seniors and friends for their opinions and
preferences before making a final decision.
Having said all this, there are some textbooks which most
students and staff have found useful and relevant in the past.
The names are as follows:
Anatomy
Recommended:
1. Clinical Anatomy by Snells 8th edition 2008
2. Clinically Oriented Anatomy by Keith. L. Moore 5th edition
2006
3. The Developing Human by Moore & Persaud 7th edition 2006
4. Basic Histology by Luiz Carlos Junqueira 12th edition 2010
Reference:
1. Last's Anatomy by RJ Last 11th edition 2006
16
2. Langman’s Embryology 10th edition 2006
3. Wheater’s Functional Histology, 5th Edition 2006
4. DiFiore’s Atlas of Histology 11th Edition
Physiology
1. Textbook of Human Physiology
(Guyton
and
Hall)
11th
Edition
2. Human
Physiology
From
Cells
to
Systems
(Lauralee
Sherwood) 6th Edition
Biochemistry
Recommended:
1. Lippincot’s Biochemistry review 4th edition
2. Harper’s Biochemistry 28th Edition
Reference:
1. Mark’s Biochemistry 3rd Edition
Clinical
Macleod’s Clinical Examination 12th Edition 2009
Websites

http://www.med.umich.edu/lrc/Hypermuscle/Hyper.htm

http://www.ptcentral.com/muscles/

http://www.vesalius.com/
For clip art:
http://www.clipartpal.com/clipart/science/anatomy1.html
17
Study Tips:
1.
2.
3.
4.
5.
6.
We encourage you to study and work in small groups
(maximum three) while preparing for SGD, dissection or
large group discussion.
Quiz each other and discuss complex topics. This will help
you in clarifying misconceptions.
Make sure you see and recognize the structures on the
cadaver when having a session in the dissection hall.
These structures are often asked in the IPE examination.
See the objectives and prepare for sessions before hand.
Study a little bit every day.
If you have any questions, or you are not doing as well as
you would like to do, please see us right away!
We want you to Succeed and we are here to help.
Good Luck!!!
18
THEME 1: Skeletal support & Body movements
Video clip
Knowledge
a) Describe anatomical planes, terms of position and movements.
b) Classify muscles on the basis of their structure and function.
c) Classify bones according to their shape.
d) Classify joints.
e) Correlate histological features of bone and cartilage to their
functions.
Skill
a) Identify various muscle groups according to their functions
(prime movers, antagonists, synergist and fixators).
b) Demonstrate various movements at the joints of upper limb,
lower limb and back.
c) Identify bones according to their shape. (models/X-rays/CT)
d) Identify joints according to the manner and type of articulating
material.
e) Take history in the context of locomotor system.
Attitude: Students should develop the following attitudes:
a) Responsibility to remain a life-long learner and maintain the
highest ethical and professional standards.
b) Willingness to work in a team with other health professionals
19
20
c) THEME
2:
Growth
and
Development
of
Human
Musculoskeletal System
Knowledge
a) Correlate the process of osteogenesis and myogenesis to
its anomalies.
b) Describe developmental anomalies of limbs and joints
c) Discuss calcium homeostasis and the common causes of
hypercalcemia and hypocalcemia.
d) Discuss phosphate homeostasis and the common causes of
hyper- and hypo- phosphataemia.
e) Classify collagen and its types.
f) Illustrate the synthesis and distribution of different types
of collagen.
g) Outline the process of fracture healing.
Skill
a) Identify gross features of bones of the upper and lower limb
(specimens/ models /x- ray/ CT).
b) Identify histological features of bone and cartilage under light
microscope.
c) Identify the developmental anomalies of limbs and spines on
specimen/diagram
21
Attitude
d) Counsel an individual/community on the role of dietary and
environmental factors for prevention of bone and joint
diseases.
CASE 1: Seven month old boy with history of
repeated fractures
Name: Ihsan
Age: 7 Months
Presenting Complaint:Painful swollen right leg for 2hrs
History of Presenting Illness:Seven months old boy is brought to the emergency room with
complain of swelling and pain in right lower limb after a fall while he
was crawling on the bed.
Past History:
Patient had a right humerus fracture 2 months back and left femoral
fracture 4 months back
Family history: Collagen diseases.
Social History: Not significant
General Physical Examination: Seven months old boy with thin
bones, presently in distress.
22
Vitals:
Pulse: 130/min
Respiratory Rate: 35/min
BP: 110/70 mm Hg
Temperature: Afebrile
Systemic Examination:
CVS: Normal.
Resp: Normal vesicular breathing.
Abdomen: Soft, on tender abdomen.
CNS: Normal.
Investigations:
X-Ray lower limb: thin bones with few trabeculae and thin cortices.
Diagnosis: Osteogenesis imperfecta
Critical Questions:
(1) Describe
the
composition,
structure
and
extracellular matrix including collagen and elastin.
23
functions
of
(2) Describe the synthesis and degradation of collagen with
associated defects.
(3) Discuss the non-collagen components of bone matrix.
Collagen disease, thin bone, trabeculae, cortices and osteogenesis
imperfect.
CASE 2: 72 YEAR OLD WOMAN WITH FRACTURE
A 72-year-old woman has been living alone since the death of her
husband 5 years ago. She spends her days mainly at home
housekeeping, reading, and rarely goes out. She has been suffering
from backache for the past one year and this is perhaps one reason
why she is not as physically active as she should be. She lives mainly
on canned food, soft drinks and fast food with no milk and milk
products. One day she fell from the stool she was standing on.
Immediately she felt a sharp pain in her right hip joint and was unable
to bear weight. She presented to the emergency department with a
fracture of the neck of femur shown by X-Ray of the hip joint. Other
blood tests revealed:
Hemoglobin = 10 g/dl,
Na+: 144 mmol/liter (136 to 145),
K+: 3.6 mmol/liter (3.5 to 4.5),
Ca2+: 1.55 mmol/liter (2.20 to 2.55) and
24
Serum Phosphate = 0.52 mmol/liter (0.74 to 1.20).
Alkaline Phosphatase = 380 U/liter
Serum Parathyroid Hormone = increased.
A radioimmunoassay for vitamin D showed that the blood level of 25OH-vitamin D3 was 2 ng/mL (normal, 14 to 60 ng/mL).
Critical Questions:
1.
Explain
calcium
and
phosphate
homeostasis
and
factors
regulating serum calcium.
2.
Describe different forms of vitamin D and its metabolism in
health and disease.
3.
What difference would you see in a normal X-ray of hip joint
taken from a 72 year old woman and a ten year old girl?
4.
How does healing occur in bone?
5.
What are the cells involved in healing?
6.
What factors influence bone formation?
7.
What is osteoporosis?
25
8.
Where are spongy and compact bones found?
9.
How do they differ histologically?
10.
Which part of the bone is mostly affected in this type of fracture
and what is the mechanism?
Backache, canned food, milk, fracture of neck of
femur,
hemoglobin,
parathyroid
calcium,
phosphate,
hormone,
26
alkaline
Vitamin
phosphate,
D.
THEME 3: Muscle weakness
Knowledge
a) Correlate the histological features to the molecular basis of
skeletal muscle contraction.
b) Illustrate the mechanism of generation of Resting Membrane
Potential.
c) Compare isotonic and isometric contraction in various body
movements.
d) Correlate the histological features of skeletal, smooth and
cardiac muscle to their function.
e) Correlate the energy sources of white and red skeletal muscle
fibers to their use in sprinters and marathon runners.
f) Describe neuroanatomic basis of flaccid and spastic paralysis
(myasthenia gravis)
g) Correlate the common injuries of lumbosacral plexus to their
clinical presentation.
Skill
h) Differentiate the histological features of skeletal, smooth and
cardiac muscle under a light microscope.
i) Identify muscles of the lower limbs, their attachments and
nerve supply on cadaver, specimen, model and imaging.
j) Perform muscle function testing (in lower limb) by reciprocal
peer teaching.
k) Interpret the graph of an action potential with underlying
mechanism responsible for different phases of action potential.
27
l)
Interpret the graphs of simple muscle twitch and repetitive
muscle contraction.
m) Identify the role of different factors influencing the speed of
conduction of an impulse.
n) Draw and label lumbosacral plexus.
Attitude: Take informed consent before examination
CASE 3: Boy with broken tooth and severe pain
Name: Ibrahim
Age: 9 years
Presenting Complaints:
Tooth ache for 4 hours
History of Presenting Illness:
While playing, Ibrahim sustained an injury which resulted in a partially
broken tooth (upper jaw incisor). Following this, he has severe pain
and has difficulty in eating. During his dentist’s visit, he was advised
complete tooth extraction under local anesthesia.
Past Medical History: Not significant
Family History: Not significant
Social History: Not Significant
28
General Physical Examination:
A young boy sitting anxiously, oriented in time place and person
Vitals
Pulse: 100/min
BP:110/70mmHg Temp:98.6 F
RR:18/min
Systemic Examination
HEENT: Normal
Respiratory: Normal
CVS: Normal
Abdomen: Normal
CNS: Normal
Critical Questions
1.
How resting membrane potential is generated?
2.
Describe the role of different ions in the generation of resting
membrane potential?
3.
What is significance of sodium potassium pump in generation of
concentration gradient inside with respect to outside and in the
generation of resting membrane potential?
4.
What mechanism is responsible for the transmission of pain from
tooth to brain?
Pain and anesthesia
29
CASE 4: 35 year old woman with progressive muscle
weakness
A 35 years old woman resident of Rawalpindi presented in foundation
OPD with progressive weakness for the last 2 months. She has also
noticed intermittent drooping of both of her eye lids, and progressive
facial muscles weakness while speaking. She also complaints of
weakness and tiredness while climbing the stairs of her office has
difficulty while typing a lengthy official replies to their clients. Her
general physical examination revealed a pulse of 82/min. B.P 120/80
mm of Hg. Temp. 98 F and Resp. rate 16/min. with drooping of both
eyelids ( Ptosis +ive). Her laboratory investigations revealed positive
anti-choline receptor antibodies. Rest of laboratory workup was
unremarkable.
Critical Questions:
1. What is wrong with this patient?
2. What is the cause of this condition?
3. What is the physiological basis progressive muscle weakness &
drooping of eyelids?
4. How can this patient be helped?
Progressive weakness, drooping of eyelids, anti-Ach receptor antibody
30
CASE 5: 21 Year old man with progressive stiffness &
difficulty swallowing
A 21-year-old man presents to a rural emergency center with a 1-day
history of progressive stiffness of the neck and jaw, difficulty
swallowing, stiff shoulders and back, and a rigid abdomen. Upon
further questioning, the patient reports that the stiff jaw was the first
symptom, followed by the stiff neck and dysphagia.
On examination, he is noted to have stiffness in the neck, shoulder,
and arm muscles. He has a grimace on his face that he cannot stop
voluntarily and an arched back from contracted back muscles. The
physician concludes that the patient has tetanic skeletal muscle
contractions. A 3-cm laceration is noted on his left foot. The patient
reports sustaining the laceration about 7 days ago while he was
plowing the fields on his farm. He has not had a tetanus booster. He is
diagnosed with a tetanus infection, and an injection of the tetanus
antitoxin is given.
31
Critical Questions:
1.
On which skeletal muscle filament is troponin located?
2.
What is the function of the sarcoplasmic reticulum?
3.
What is the molecular basis for the contraction of skeletal
muscle?
4.
Why is a skeletal muscle tetanized?
5.
Which part of the body is safe from tetanization?
6.
What is a sarcomere and how its length changes?
7.
What keeps actin and myosin in place?
8.
What is the walk along mechanism of muscle contraction?
9.
Why dark and light bands are named so?
SGD II
10. How
muscle is able to produce tension of different grades?
11. Give
examples of the two types of muscle contraction from daily
life?
12. What
are antigravity muscles?
13. How
a person is able to stand over long periods of time?
Progressive stiffness, dysphagia, involuntary grimace, arched back,
tetanic skeletal muscle contractions, lacerations, tetanus, tetanus
booster, tetanus antitoxin.
32
CASE 6: Patient with cramps and pain in both calves
Name: Rahmat Ali
Age: 30 years
Presenting Complaint:
Severe
cramps
and
pain
in
calves ---- 03 hours
History of Presenting Illness:
According to the patient, he was in his usual state of health 3 hours
ago when started having severe cramps and pain in both calves. He
has just returned from a hiking trip with his friends in Margalla hills
which lasted for around 4 hours. The pain started gradually after the
first hour but he kept on moving. It got better when they stopped to
have lunch but recurred as soon as they started moving back. He
complains of similar pains of lesser severity when he goes out on
weekends.
Past medical history – Not significant
Family History - Not significant
Social History - He is a software programmer, who works from home
and rarely goes out.
General Physical Examination
A young man in pain lying on a bed, well-aware of his surroundings.
Vitals:
Pulse: 80/min
Respiratory rate: 18/min
33
B.P.: 110/70 mmHg
Temperature: Afebrile
Systemic Examination
HEENT: Normal
Respiratory: Normal
CVS: Normal
Abdomen: Normal
CNS: Normal
Musculoskeletal:
His calves are tender to touch, although there are no signs of acute
inflammation.
Critical Questions
1. Compare and contrast between fast and slow muscle fibers in
relation with.
2. Why do the muscles of body go into state of permanent contraction
after death?
3. What are the differences between skeletal, smooth and cardiac
muscles?
Cramps, tender calves
34
THEME 4: Painful Joint
Knowledge
a) Correlate the structure of major joints in the human body to
its functions.
b) Discuss the role of raised serum uric acid in joint pain.
c) Correlate the composition of synovial fluid to its role in joint
function.
d) Describe glycosaminoglycans and their role in regular wear
and tear of joints.
e) Discuss the epidemiology and prevention of rheumatic joint
disease.
Skill
f) Identify normal & diseased joints of the limbs by clinical
examination and imaging modalities.
Attitude
g) Counsel an individual on basic road traffic rules.
h) Counsel an individual on healthy practices to prevent joint
disease.
35
CASE 7: PBL
Case will be provided in the class on the day of instruction.
CASE 8: Businessman with pain in big toe
NAME:
David Bahadur
AGE: 52 years
Presenting complaint:
Pain in big toe for 12 hours
History Of Presenting Illness
According to the patient, he was in his usual state of health, when he
went to a dinner party yesterday. There he had an episode of binge
eating and drinking beer.
He had no complaints until early this
morning when he started to have pain in his big toe. The pain was
gradual
in
onset,
severe
in
intensity,
non-radiating
with
no
aggravating or relieving factor.
Past history: He had a lithotripsy for kidney stones 2 years back. He
had similar attacks in the past.
Family history: Not significant
Social history: He is married for 22 years having 3 children.
drinks a glass of beer every night.
36
He
General Physical Examination: A middle aged man conscious and
alert.
Vitals:
Pulse: 72/min,
Temp: 100o F
BP: 110/70 mmHg
Respiratory Rate: 20/min.
HEENT: Normal
Resp: Normal
CVS: Normal
GIT: Normal
CNS: Normal
Musculoskeletal:
The big toe was red, hot and swollen; painful to active and passive
movement; tophaceous deposits in left ear and olecranon bursitis.
Investigations:
CBC:
Hb: 12g/dl, WBCs: 12000, Serum Uric Acid: 6.5 mg/dL
X-RAY:
Punched-out erosions in right big toe at metatarsophalangeal joint,
producing “overhanging’’ spicules
37
Critical Questions
Can you think of reasons why…
a) binge eating is related to gout
b) gout primarily affects the extremities
c) gout usually affects the first metatarsophalangeal joint or the
olecranon bursa
d) attacks of acute gout mostly take place at night or the early
morning
e) more men are affected by gout than women (male : female
ratio, 3-9:1)
f) tophaceous deposits are produced
g) punched out lesions are produced
Pain in big toe, binge eating, lithotripsy, tophaceous deposits,
olecranon bursitis, uric acid, punched out erosions, overhanging
spicules.
38
THEME 5: Painful Swollen limb
Knowledge
a) Correlate the venous and lymphatic drainage of lower limb to
their clinical significance.
b) Correlate
the
causes
and
effects
of
varicose
veins
to
perforator incompetence and venous hypertension.
c) Explain the organization of arterial system supplying the
limbs and vertebral column.
Skill
d) Identify major
veins of lower
limb on cadaver/peers/
simulated patients.
e) Mark the surface anatomy of the major veins of lower limb.
CASE 9: Babloo’s increasing left leg pain
Six hours after the accident, Babloo developed increasing left leg pain.
He called out to a passing doctor who examined his leg. The leg was
swollen and tender over the posterior, anterior and lateral aspects.
Pedal pulses were weak but present. Motor power was reduced in the
leg muscles. There was also decreased sensation in deep and
superficial peroneal distribution. Active ankle planter flexion and
inversion were present but weak due to pain. Capillary filling of the
skin of the leg and foot was normal.
39
Critical Questions:
1.
Where are the foot pulses palpated and why?
2.
How will you check the motor power in this case?
3.
Why was the motor power in Babloo’s case reduced?
4.
Why was Babloo having decreased sensation in deep and
superficial peroneal distribution area?
5.
How are the compartments in the leg formed?
6.
Which muscles are present in anterior, lateral and posterior
compartments and what is the action and nerve supply?
7.
What other structures are present in the compartments?
8.
What is compartment syndrome?
9.
What are the causes of compartment syndrome and how does it
present?
10.
What could be the cause in Babloo’s case?
11.
Why did the doctor check for planter flexion?
40
12.
How is capillary filling checked?
13
What is the name of the procedure done to relieve compartment
syndrome?
Increasing left leg pain, pedal pulses, motor power, decreased
sensation, capillary filling.
CASE 10: Babloo’s uncle has tortuous leg veins
One of Babloo’s uncles serves in the Islamabad Traffic Police. He is
50–years old. He often complained of chronic dull ache in both legs
and noticed irregular swelling in both legs. A friend advised him to
consult a doctor. On examination, the doctor noticed dilated and
tortuous veins on the medial side both legs. The skin on the medial
malleolus was found to be discolored, dry and scaly.
41
Critical Questions:
1.
What is the clinical condition called?
2.
Where is the abnormality?
3.
What causes this abnormality?
4.
Who is more prone to get this?
5.
What is the structure of a vein? How does it differ from an artery?
6.
What is the direction of flow in leg veins?
7.
What are perforating veins?
8.
How does the venous system function against gravity in lower
limb (factor facilitating venous return)?
9.
Why is saphenous vein ideal for coronary artery grafts and how is
it used?
10. What is the reason for dry scaly skin at medial malleolus?
Tortuous veins, dry & scaly skin, chronic dull ache, irregular swelling
CASE 11: Fifty-five year-old man with calf pain while
walking
Name: Ayaz Akhtar
Age: 55
Presenting Complaints:
Pain RT calf for 6 months
42
History Of Presenting Complaints:
Patient was in his usual state of health 6 months back when he
developed pain in his right calf. This pain was sudden in onset,
moderate in intensity, non-radiating, aching in character. Patient
noticed that this pain begins after walking around 100 yards and is
relieved as he stops and sits for 10 minutes. For the last 2 months, the
pain begins after he walks only 50 yards and he has to stop. There is
mild discomfort in left calf but no pain. He took some analgesics but
with no relief.
Past medical History:
Known hypertensive, on irregular treatment.
Personal History:
Smoker for last 20 years, 30 cigarettes per day.
Family History:
History of obesity, diabetes and hypertension in family.
Social History: Married having 2 sons.
General Physical Examination:
An obese man lying in bed well oriented in time, place and person.
Vitals
TEMP. A/F
BP: 150/90mmHg
R/R: 18/min
PULSE: 88/min
Weight: 110 kg
43
Xanthelasmas present
Systemic Examination
Respiratory System: Normal
Abdomen: Normal
CVS: Normal
CNS: Normal
Musculoskeletal Examination:
The right leg and foot is pale as compared to left. There is hair loss
and skin is thin and shiny on right side, limb is cold as compared to
the left. No ulceration present.
Popliteal, posterior tibial and dorsal pedis pulses are absent on the
right side, while pulses on the left side are normal. There is slight
wasting of right calf muscles, while movement is normal.
Laboratory Investigations:
CBC: Hb: 12.0 g/dl; TLC: 7500 /mm3; PLT: 215000 /mm3
RBS: 146mg/dl
Urea: 35 mg/dl
Creatinine: 0.9 u
Cholesterol: 220 mg/dl
Investigations Ordered:
ECG
X Ray Chest Pa View
Doppler U/S of legs
44
Critical Questions
1. What is the condition called?
2. Why is the pain relieved at rest?
3. Why the distance is walked decreasing?
4. Why the right leg is paler compared to the left?
5. Why are the distal pulses (popliteal, posterior tibial & dorsalis pedis)
absent?
6. Why is there wasting of muscles while movement is normal on the
right side?
7. How is smoking and xanthelasmas related to his condition?
8. Why has a Doppler U/S of legs been ordered?
Sudden pain, HTN, smoker, pack years, xanthelasmas, pallor/pale,
thin & shiny skin, ulceration and muscle wasting
45
THEME 6: BIOMECHANICS OF LIMB JOINT
Knowledge
a. Discuss the biomechanics of the ankle, and subtalar joints
and the special features that help to maintain their
stability.
b. Describe the arches of foot.
c. State their functional significance in normal life and sport
activities.
Skill
d. Identify arches of foot on prosected specimen, diagram or
model.
e. Identify the bones involved in maintaining arches of foot
on articulated foot.
CASE 12: 23 year old runner with swollen ankle
A 23-year-old basketballer twisted (inverted) her right ankle during
warm-up. She complains of pain and swelling over the lateral aspect of
the right ankle. Walking is also difficult secondary to pain. Physical
exam reveals swelling over the lateral aspect, which is painful to
palpation.
46
Critical Questions:
1. What is this injury called?
2. What is the mechanism of injury?
3. Why is her ankle swollen?
4. What is the source of her pain?
5. How is this injury different from Pott fracture?
Swollen ankle, inversion
47
CASE 13: Babloo’s friend rejected for army
recruitment
Tipu is Babloo’s close friend. He likes adventures and is very keen to
join the army. Although he cleared all the tests, he was still rejected
because he was found to have pes planus (flat foot) in the medical
check up. Babloo has brought worried Tipu with him to your place for
advice. How will you explain the situation to Tipu?
Critical Questions:
1) What are the effects of flat foot?
2) Why is Tipu rejected?
3) What are the anatomical factors responsible for this condition?
4) Which bone is the keystone for the medial and longitudinal arch?
Pes planus
48
7) Nerve Injuries (Lower Limb)
Knowledge
a) Discuss the anatomical basis of peripheral nerve injuries.
b) Interpret the neuroanatomical basis of the clinical conditions
causing numbness in the limbs.
Skill
c) Identify
common
nerve
injuries
in
the
limbs
and
their
implications (pictures/videos/diagram/SP).
CASE 14: Policeman with superior gluteal nerve
injury
A policeman sustained a bullet shot injury in his left buttock in a street
encounter.
After convalescence, he developed a characteristic limp
during walking. There was sagging of right hip while taking a step on
left foot. On examination, Trendelenburg sign was positive.
49
Critical Questions:
1) Identify the nerve injured and give its course and branches?
2) What is Trendelenburg sign and what are the implications of
positive Trendelenburg test?
3) Name the characteristic gait in unilateral injury and in bilateral
injury to the nerve?
4) How does this gait abnormality occur?
Superior gluteal nerve, limp, trendelenburg sign.
50
CASE 15: Imtinan loses sensation over lateral and
anterior aspect of leg after removal of plaster
A few days following the removal of plaster cast for fracture of the
upper end of left fibula, Imtinan complained of loss of sensation on the
lateral and anterior aspect of leg and on the intermediate area of the
dorsum of foot including toes except the lateral side of little toe and
first inter digital cleft.
On examination, the Imtinan was unable to
dorsiflex and evert the left foot.
Critical Questions:
1) What is the deformity called?
2) Why is it common?
3) Which nerve is injured in this case?
4) Why is this nerve vulnerable to injury?
5) Describe the course and distribution of this nerve.
51
6) Inability to dorsiflex the foot is due to loss of function of which
nerve.
7) What are the chief evertors of foot?
Upper end of fibula, loss of sensation, dorsiflex, evert.
52
THEME 8: GAIT CYCLE
Knowledge
a) Describe the gait cycle and its phases.
b) Explain the anatomicopathological basis of different types of limp.
Skill
c)
Recognize various types of limp
VIDEO OF GAIT
53
THEME 9: LOW BACK PAIN/NECK PAIN
Knowledge
b) Correlate
the
development
of
vertebral
column
to
its
anomalies.
c)
Correlate the skeletal components of spine to its function.
d) Associate the structure of typical and atypical vertebrae with
their regional characteristics.
e) Underline the anatomical basis of acute and chronic low back
pain.
Skill
f)
Identify structure of typical vertebra and mention the regional
characteristics of the vertebrae
g) Identify salient features of cervical, thoracic, lumbar & sacral
vertebrae.
h) Using diagram and/or prosected specimens, identify the
muscles, ligaments and tendons which support and act upon
the spinal column.
54
CASE 16: Patient with abnormal curvature of spine
Mother of a teenage girl is worried about the abnormal curvature of
the spine of her daughter. The spine is crooked and curves to the side.
Her right shoulder appears to be lower than the other. The doctors told
that her daughter had scoliosis.
Critical Questions:
1) What vertebral defect can produce scoliosis?
2) What is the embryological basis of the vertebral defect?
3) Does scoliosis cause any problem?
4) Define kyphosis and lordosis. Explain the factors responsible for
these defects?
Curvature of spine, scoliosis
55
CASE 17: Rashid and the heavy box
Thirty
five
year-old
Rashid
disc
in
the
posterolateral
works as bellboy in a 5-star
direction between L4 and L5
hotel. He has developed sudden
vertebrae.
and acute pain in lumbar region
after lifting a heavy box of a
foreign guest. The pain radiates
down to the outer side of the
left leg. MRI of the vertebral
column showed herniation of the
Critical Questions:
1) Which nerve root will be compressed if there is a disc prolapse
between L4 and L5 vertebrae?
56
2) In which area will there be sensory loss in a disc prolapse at this
level?
3) Name the parts of an intervertebral disc.
4) Enumerate the functions of the disc and describe the diurnal
variations in it.
5) What are the age related changes seen in disc?
6) What effects do they produce on posture?
7) Define lumbago and sciatica.
Lumbar region, radiating pain, herniation.
CASE 18: RAJ’S TERRIBLE BACKACHE
One day, Shazina came home
from shopping to find Raj in
agony. “I have a terrible back
ache”, he groaned, “Probably
will have to go off sick again”.
“Well you’ll have to go and see
Dr.
Masroof,
Shazina
won’t
said
you?”
rather
unsympathetically.
57
Dr. Masroof asked Raj to bend forward, backwards and rotate his trunk
from side to side.
He was examining his range of movements.
Dr.
Masroof then tested Raj’s ability to passively raise his legs while lying
down. Dr. Masroof asked Raj “Where is the pain?”
Raj indicated his lower back, midway between his anterior superior
iliac spines. “Does the pain run down your leg?” inquired Dr. Masroof.
Raj said no.
Critical Questions:
1) Which muscles are being used by Raj to extend, flex and rotate his
spine?
2) Why did the doctor inquire about pain running down the leg?
3) Where are the paraspinous muscles located? What are their
functions?
Backache
58
THEME 10: AMBIVALENCE ABOUT SPORTS
KNOWLEDGE
a) Correlate hypertrophy and atrophy of muscle with its use and
disuse.
b) Explain the physiological basis of performance-enhancing drugs.
c) Correlate the common injuries of brachial plexus to their clinical
presentation
d) Correlate the structure of major joints in upper limb to its
functions.
e) Correlate the venous and lymphatic drainage of upper limb to
their clinical significance.
f) Explain the organization of arterial system supplying the upper
limbs and neck.
g) Discuss the biomechanics of the shoulder, elbow, and wrist, and
the special features that help to maintain their stability.
h) Interpret the anatomical basis of common traumatic/sports
injuries of the bones, joints and soft tissues of the limbs.
SKILLS
a) Identify gross features of bones of upper limb (specimens/
models /x- ray/ CT).
b) Identify muscles of the upper limbs, their attachments and
nerve supply on cadaver, specimen, model and imaging.
c) Perform muscle function testing (in upper limb) by reciprocal
peer teaching.
d) Draw and label brachial plexus
59
e) Identify normal & diseased joints of the limbs by clinical
examination and imaging modalities
f) Identify
major
vessels
of
upper
limb
on
cadaver/peers/
simulated patients.
g) Mark the surface anatomy of the major vessels of upper limb.
h) Perform intramuscular injection on mannequin (deltoid & gluteal
region)
ATTITUDE
i) Counsel a person using performance-enhancing drugs for long
periods.
j) Demonstrate
process
of
taking
informed
consent
for
examination/intramuscular injection on SP.
CASE 19: 24 year old weight trainer sent for
counseling
Rashid, a 24 year old male had weight trained steadily for over the
past year to compete in the city bodybuilding event.
competition,
he
employed
restrictive
dietary
Prior to the
practices,
intense
exercise, and the self-administration of pharmaceuticals to reduce
body fat and to gain lean body weight. He recorded his nutritional
intake, pharmaceutical use, body weight, and skin fold measurements
regularly. He also administered a variety of anabolic-androgenic
steroids in various dosages and combinations.
60
At the end of his training, his records indicated a weight gain from 160
to 238 lbs. He competed and won the city championship. Six months
later, he reappeared in an intercity championship weighing 190 lbs but
was disqualified from the competition after testing positive for drugs.
Authorities have sent him to you to for counseling.
Weight trainer, body fat, lean body weight, anabolic steroids.
CASE 20: PBL Babloo and his new motorbike…
Case will be provided in the class on the day of instruction.
CASE 21: Goalkeeper with pain in shoulder and long
arm
The goalkeeper in a soccer match fell on his outstretched left arm. He
felt an immediate pain in the shoulder region and was unable to move
his arm. At the hospital the arm was abducted and the deltoid muscle
looked flat or hollow. The injured arm looked "too long", and there was
intense pain on attempting to move the arm. A plain radiograph of the
region showed that the humeral head was lying below the glenoid
labrum and that there was no fracture of the humerus. The diagnosis
61
was an anterior dislocation of the shoulder, and the orthopedic
surgeon recommended Kocher's maneuver for management.
Critical Questions:
1. Why did the deltoid appear flat and hollow?
2. What neurovascular structures are liable to be injured in such a
condition? How do you examine the patient to rule that out?
3. What is the anatomical principle in reducing a dislocated shoulder?
4. How is the shoulder joint formed?
5. Draw a diagram to show the relations of the shoulder joint
6. What is anterior dislocation of shoulder joint?
7. After retracting the deltoid and pectoralis major muscles from each
other, which bony part of the scapula is exposed?
8. Which long blood vessel is located in the deltopectoral groove?
9. Name the two muscles which are attached to the bony part of the
conjoint tendon?
10.
Name the rotator cuff muscles and give nerve supply of each.
62
11.
What is the significance of rotator cuff muscles?
Outstretched left arm, shoulder, deltoid flat or hollow, arm too long,
glenoid labrum, anterior dislocation, Kocher’s maneuver
CASE 22: Wrestler with severe pain in his left elbow
A 20 year old wrestler presents to the Emergency Department after
being thrown out of the ring and landing on his left hand.
He
complains of severe pain in his left elbow, swelling and the area
appears widened as compared to the right. He resists examination by
the doctor as slight attempt to move the elbow elicits severe pain. A
lateral view of the left elbow joint is ordered. The following image
returns:
63
CRITICAL QUESTIONS:
a) What is wrong with this patient?
b) What is the basis of this injury and why?
c) What are the bony landmarks that are readily palpable at the
elbow?
d) What nervous structure is particularly vulnerable in elbow injuries
and where is it located?
e) What other types of elbow injuries are common and how do they
present?
f) What type of elbow injuries are common in pre-school children?
Elbow, lateral view of left elbow
CASE 23: Basketballer with swollen wrist
A 27-year-old-male basketball player presents to the emergency room
following an awkward landing after a rebound in which he landed on
his right hand. He was unable to carry on playing and reports that his
right wrist became immediately swollen. On examination, the patient's
right wrist is swollen with marked "dinner fork" deformity. There is
64
tenderness over the distal radius and hypoesthesia in the distribution
of the medial nerve.
Critical Questions
1. What is the basis of this injury?
2. Why is it called a dinner fork deformity?
3. How does Colle’s fracture differ in children?
4. Why is his wrist swollen?
5. What is mallet finger?
Swollen wrist, dinner fork deformity, hypoesthesia, median nerve
65
CASE 24: Hunter with bullet injury of right arm
Sher Dil
28 years old
Male
Computer Programmer
Presenting Complaints:
Bullet injury right arm for 3 hours
History Of Presenting Complaints:
Patient was in his usual state of health and hunting ducks with his
friends 3 hours ago. After shooting at a flock of duck and successfully
hitting one, he went to collect his prize. While picking up the shot
duck, it resisted and in the commotion, his gun went off and injured
his right arm. He fell unconscious and was later taken to the local clinic
by accompanying hunters. There initial bandage was done and he was
referred to a tertiary care hospital. He is complaining of severe pain in
his arm, forearm and right hand. He received some analgesics at the
local clinic but the pain is worsening.
Past medical History: Not significant.
Family History: History of tuberculosis in family.
Personal History: No known addictions.
Medication History: Not significant.
Physical Examination:
A young man lying on couch, in severe distress due to pain, well
oriented in time, place and person.
ABCDE of trauma protocol done
66
BP: 100/90mmHg
PULSE: 110/min
TEMP. A/F
R/R: 20/min
Musculoskeletal Examination:
The right arm is bandaged, soaked with blood, forearm and hand
appears dusky colored, pale and colder as compared to left side. On
removing the bandage, wound of entry on medial side of mid arm with
exit wound on lateral side. There is swelling of the arm with absent
distal pulses.
Respiratory System: Normal
Cardiovascular System: Normal
Abdomen: Normal
Investigations:
CBC and Blood Grouping sent.
X-RAY Right Arm AP LAT views ordered.
Critical Questions:
1. What is ABCDE of trauma protocol?
2. Why is his right arm dusky colored, pale and cold?
3. Which artery is the source of bleeding?
4. Why is his arm swollen?
5. What is the purpose of palpating distal pulses?
6. Why are distal pulses absent?
7. Are there any other conditions in which distal pulses are absent?
8. What do you expect to see in his CBC?
67
9. Why was an X-ray ordered?
10.
Are there any other tests that you would like to perform?
Analgesics, soaked with blood, dusky color, entry wound, exit wound,
absent pulses.
68
THEME 11: STIFF NECK
Knowledge
a) Describe deep cervical fascia and division of neck into various
compartments.
b) Describe triangles of neck and their contents.
c) Enumerate causes of cervical pain.
Skills
a) Identify salient features of cervical vertebrae.
b) Identify various triangles of neck and structures contained.
c) Identify the cervical vertebrae on radiographs.
CASE 25: 52 year old woman with neck stiffness
A 52-year-old woman presents with a history of several months'
duration of involuntary spasms in her neck. She relates intermittently
feeling the muscles in her neck tighten painfully. The episodes cause
her head to turn slightly to the right. She has difficulty looking over
her left shoulder when the muscle spasm occurs, which is particularly
bothersome while driving. She has symptoms daily, and notes that
symptoms are worse late in the day. They are exacerbated by fatigue
and emotional stress. She can partially relieve symptoms by placing
her hand on her chin during the spasms.
69
Critical Questions:
1. What is the source of pain in her neck?
2. Why is her head turned to the right?
3. Why are the symptoms exacerbated by fatigue and stress?
4. Why are the symptoms relieved by placing her hand on the chin?
Involuntary spasms, head turned to right, difficulty looking over left
shoulder, muscle spasms.
70
Glossary

Abduction
movement away from the central axis of the
body/limbs.

Acetabulum
the cuplike cavity on the lateral aspect of the hip
girdle that receives the head of the femur

Adduction movement towards the central axis of the body/limbs.
Anastamosis
the union or joining of blood vessels (also used to
describe surgical joining of tubular structures

Anterior the front of an organism, organ or body part; same as
ventral

Aponeurosis a broad flattened tendon.

Appendicular referring to the bones of the limbs and limb girdles
that are attached to the axial skeleton

Axial
referring to the bones of the skull, vertebral column and
bony thorax that form the central axis of the body Bursa a fibrous
sac containing fluid that occurs between bones and tendons where
it acts to decrease friction during movement Caudal
literally
towards the tail; in humans, towards the inferior portion of the
trunk Condyle
rounded projection at the end of a bone that
articulates with another bone

Circumduction a movement in which the limb describes a cone. It
is not a primary movement, but in fact, a sequence of flexion,
abduction, extension and adduction.

Diaphysis
the elongated shaft of a long bone Distal
away from
the attached end of a structure, especially a limb Dorsal posterior;
pertaining to or towards the back; opposite to ventral Epicondyle
71
an elevation placed above the articular surface of a condyle.
Epiphysis
that part of a bone formed from a secondary center of
ossification, commonly found at the ends of long bones on the
margins of flat bones, and at tubercles and processes during the
period of growth, epiphyses are separated from the main portion of
bone by cartilage.

Facet
smooth, somewhat flat surface on a bone for articulation.
Fascia membranous structure of collagen fibres, with these fibres
arranged in two directions intersecting each other. It may be pulled
maximally until the fibres are perpendicular to each other.

Foramen hole in the bone.

Fossa depression on a bony surface.

Fovea small depression on a bony surface.

Gomphosis
joint in which a peg shaped process is inserted in a
socket, connected to each other by fibrous tissue. Hamulus a hooklike process.

Incisura a notch Inferior below; toward the feet; same as caudal
Insertion
the movable point at which the force of a muscle is
applied. Ligament a band of fibrous tissue that connects bones on
cartilages, serving to support and strengthen joints.

Lumbar
region of the back between the thorax and the pelvis
Motor Unit the motor neuron together with the muscle fibres that it
innervates. It varies in size greatly for extraocular muscles. It is 510 muscle fibres per motor nerve while for gastrocnemius it is 1600
1900 muscle fibres per motor nerve.

Origin the more fixed attachment of a muscle. Posterior towards
the back; same as dorsal Profundus deep; farther from the body
surface. Prone
refers to the body lying horizontally with the face
downward; opposite of supine Proximal towards the attached end
72
of a limb or near the origin of a structure Ramus a broad process
projecting from the main body. Sagittal plane
the vertical plane
dividing the body into left and right portions

Sherrington’s law
The principle of reciprocal innervation of
muscles. The contraction of a group of prime movers is under
normal circumstances always accompanied by a corresponding
degree of the appropriate antagonists.

Sulcus a groove or furrow on the bone.

Superior closer to the head; above

Supine refers to the body lying horizontally with the face upward;
opposite of prone

Suture
a fibrous joint found only in the skull, in which articular
surfaces of the bones are connected by a thin layer of fibrous tissue
(the sutural ligament).

Symphysis a secondary cartilaginous joint, in which the articular
surfaces of the bone are covered by hyaline cartilage and are
connected to each other by fibrocartilage. This joint is of a
permanent nature and some movement is permitted (e.g. pubic
symphysis).

Synarthrosis an immovable joint

Synchondrosis a primary cartilaginous joint where the interposing
tissue is hyaline cartilage and no movement is permitted.

Syndesmosis fibrous joint where the bones are connected by an
interosseous ligament, at which practically no movement can take
place. (e.g. tibiofibular syndesmosis).

Synovial
referring to the lubricating and nourishing fluid or the
membrane which produces it; this fluid is found in freely mobile
joints with articular cartilages and within the coverings of some
tendons
73

Tendon
cord like structure composed of numerous parallel
fascicles of collagen fibres, by which a muscle is attached.

Trochanter
large blunt process on a bone; best known on the
upper aspect of the femur

Tubercle small rounded process on a bone

Tuberosity
large or broad process on a bone; larger than a
tubercle
74