2. Chapter outlines Physiological functions of the skeletal
system Main anatomical components of the skeletal system General
Histological aspects. Types of bone tissues and types of cartilage
tissues Categories and examples of bones , bone markings
(projections and depressions) Anatomy of the skeleton ( bone ,
cartilage) The joint (articulation ) anatomy and different joints
types The muscular system : -Functions of muscular system.
-Histological and anatomical aspects , -Types of muscle tissues
-Properties of muscle tissue2 3. 3 Exhibit 1 4. The skeletal system
consists of :Bone Cartilag eSkeletal system 4 5. Skeletal system
construction Starting from the basic functional and structural unit
of organism which is the cellCelltissueorganssystemorganism5 6. 6
7. Bone Composition Matrix Calcium carbonate and calcium phosphate:
Make up 60-70% of bone weight Provide much of the bones stiffness
and resistance to pressing or squeezing forcesCollagen (a protein):
Gives bone its characteristic flexibility and contributes to its
ability to resist pulling and stretching forces With aging,
collagen is lost progressively and bone becomes more brittle.Water
Bone consists of much smaller proportion of water than other body
partsScattered cells The matrix is filled with living bone cells;
such as: 1- osteoblasts: bone forming cells that cover new bone.
Make up the matrix . 2- osteocytes: these are mature osteocytes
buried in the matrix in small cavities called lacunae , and they
maintain bone structure interconnected with other osteocytes by
their cytoplasmic processes (gap junction formation)through
canaliculi , also they act as mechanosensory cells that sense
mechanical stress, respond by stimulating osteoblasts and
osteoclasts remolding3- osteoclasts: large multinucleated absorbs
and remove osseous tissue. By (collagenase & acids) As well as
blood vessels that supply the cells with nutrients7 8. Bone marrow
Highly specialized connective tissue There are 2 types of bone
marrow : Red marrowYellow marrowBlood cell formation occurs in red
bone Store fat for the body ,found mainly in marrow , which is
primarily stored in the hollow spaces in the long bones of spongy
bone adults8 9. Cartilage9 10. Types of bones tissuesBone
PorosityHigh (Low mineral content and high collagen)Low (High
mineral content and low collagen)StructureHoney
combCompactCharacteristicProvides more flexibility but is not as
stress resistantStiffer and can resist greater stress but less
flexibleFunctionShock absorption due to its better ability to
change shape are important It contains red marrow.Withstanding
stress in body areas that are subject to higher impact loadse.g.,
vertebrae , ribs, skull , sternum, and pelvis of adultsLong bones
(e.g., bones of the arms and legs)Location10 11. Hyaline
cartilageFibrocartilageElastic CartilageMost abundant in the body
Provide support and flexibilityIt is strong and rigidProvides
strength and maintains shape in the structures it forms.-Covers
bone end ( articular cartilage) -At the end of the ribs its called
costal cartilage -Forms part of the nose , larynx , trachea ,
bronchi , and bronchial tubes.It joins the anterior pelvic bones at
the symphysis pubis It forms the discs that lie between the
vertebraeFound in larynx , external ear , and Eustachian
tubesBluish white in color , has glossy appearance. Transparent
collagenous fibers, lacunae have abundance of chondrocytesFormed of
bundles of visible collagenous fibers with chondrocytes scattered
throughoutHas threadlike elastic fibers that contain chondrocytes
11 scattered throughout the lacunae 12. Hyaline cartilage
Histological appearance And sitesFibrocartilage Histological
appearance And sitesElastic Cartilage Histological appearance And
sites12 13. Categories and example of bones 13 14. Example: the
femur, tibia, and fibula of the legs; the humerus, radii, and ulnae
of the arms; metacarpals and metatarsals of the hands and feet, the
phalanges of the fingers and toes, and the clavicles or collar
bones.Mainly made of spongy bone , and contains bone
marrowPeriosteum : dense white fibrous membrane that covers the
external surface of the boneMiddle section of long bone Made mainly
of compact bone14 15. Sesamoid bones is a unique type of bone that
forms within tendons small rounded , including:In the knee : the
patella (within the quadriceps tendon).In the hand two sesamoid
bones are commonly found in the distal portions of the first
metacarpal bone (within the tendons of adductor pollicis and flexor
pollicis brevis). There is also commonly a sesamoid bone in distal
portions of the second metacarpal bone. In the foot - the first
metatarsal bone usually has two sesamoid bones at its connection to
the big toe (both within the tendon of flexor hallucis brevis)16
16. Bone Markings types of bone markings: Projections (aka
processes) that grow out from the bone Depressions (cavities) that
indent the bone17 17. Projections Ligaments & tendons
projectionsJoints projections 1) Condyle: Rounded articular
projection2) Head: bony expansion on a narrow neck1)Crest: Narrow
ridge of bone2) Epicondyle:Raised area on or above a condyle3)
Tubercle: Small rounded projection 3)Facet: smooth, nearly flat
articular surface4) Ramus: Armlike bar of bone4) Tuberosity: large
rounded or roughened projection 5) Trochanter: very large, blunt
projection (only on femur)18 18. Other bone markings important for
coding It is a prominent projectionRound opening through a bone 19
19. The skeleton The appendicular skeleton: refers to the upper and
lower limbsappendicul arThe axial skeleton: is formed by the bones
and cartilaginous tissue in the skull , vertebral column , and
thoracic cageskeletonaxial 20Exhibit 4 20. 21 21. 22 22. The Facial
bones The facial bones provide the facial structure andprovide
attachments for the muscles that control facial and jaw movement.
The face consists mobile bone. of 13 stationary bones and one The
mandible (jawbone) is the only facial bone that moves and is also
the largest and strongest bone of the face. The remaining bones of
the face are:23 23. 1. 2. 3.Two palatine4. 5. 6.Two lacrimal7.Two
maxilla Two zygomatic (cheekbones) Two nasalTwo inferior nasal
concha (thin, curved bones that form the lateral walls of the nasal
cavity Vomer (located along the midline of the nasal cavity forming
part of the nasal septum)24 24. 2-The vertebral column composed of
26 individual bones. Of these bones, 24 are vertebrae that are
separated by cartilage called intervertebral discs. supports the
head and trunk of the body and protects the spinal cord. Exhibit
425 25. The parts of vertebra common structure consisting of abody,
pedicles, and lamina that form the vertebral arch. The body and
arch come together and form an opening called the vertebral
foramen, through which the spinal cord passes26 26. 27 27. -12
pairs of flat bones known as the ribs articulate with the thoracic
vertebrae . -The first seven pairs of ribs meet up with the sternum
directly via costal cartilage. The cartilage for the next three
pairs of ribs joins with the costal cartilage of the seventh rib.
The last two rib pairs do not join the sternum at all (called
floating ribs)28Exhibit 5 28. Function of thoracic cage It also
supports the shoulders and upper limbs. It protects important
internal organs ;as the heart and the lung It gives attachments to
muscles of the upper limb and shoulder Exhibit 629 29. 30 30. The
upper limb + shoulder girdle Exhibit 731 31. The wrist The wrist is
composed of eight short bones called carpals that meet with the
radius andulna.32 32. The lower limb and pelvic Girdle(hip)Exhibit
8Bones of the foot (tarsal , metatarsal , phalanges ) 33 Exhibit 9
33. Articulations (joint)Articulations, or joints, join two bones
together and allow for movement in response to muscle
contractionsFibrousCartilaginousheld together by dense tissuejoined
by cartilageSynovial have a fluid-filled cavity separating the
bones it joins; called the synovial cavity fluid is Synovial fluid
The joint cavity is surrounded by a twolayer capsule called the
articular capsule.limited in movement1-sutures: or seams, bones
held together by connective tissue, such as those found in the
cranium. 2-Gomphosis:found only as a tooth in its socket
3-syndesmoses:bones joined by a ligament as articulation between
the tibia and fibulaDo provide for somefree moving and therefore
structurallymovementmore complexThe first rib to themajority of
joints in the human bodysternumIt is reinforced by ligaments35 34.
Fibrous jointsSuture joint of the skullGomphosis jointSyndesmoses36
35. Cartilaginous joint Joints between the ribs and the sternum37
36. 38 37. 2- CondyloidThese types of joints move in all
directions. An example is the hip joint ; Articulation between the
head of the femur and the acetabulumProtrusion of one bone meets a
depression of another to form this type of joint. Examples are the
wrist (radius and carpals) and Knuckles ) metacarpal and proximal
phalanges. Convex portion of a bone meets with the concave part of
another to form a hinge joint. It allows movement in one axis
Example: The elbow and knee are large hinge joints.Roundedor
pointed protrusionof one bone moves back and forth is a pivotFlat
surfaces of 2 flat bones glide against one another examples The
jointsbetween the short carpals ( intercarpals ) The jointsbetween
the short tarsals ( intertarsals )One bone has a depression shaped
somewhat like an equestrian saddle. the joint is formed by a second
bone straddling that depression. Allows the unique opposition of
the human thumb.joint 39Exhibit 10Exhibit 11Exhibit 12Exhibit
13Exhibit 14Exhibit 15 38. 40 39. Functions of the muscular
system41 40. Muscles construction Starting from the basic
functional and structural unit of organism which is the cell Cell
(fibers) tissue organs system organism42 Exhibit 16 41. Properties
of muscle tissue Irritability : Ability to electrically respond to
stimuli Contractility : Ability to shorten and thicken when
sufficient stimulus is received Extensibility : Ability to be
stretched when pulled. Elasticity : Ability to return to their
original shape after contraction or extension 43 42. Types of
Muscle Tissue Types and Importance of each : Skeletal muscles
Attached to the skeleton (bones) Responsible for voluntary movement
Striated,cylindrical, multinucleatedCardiac muscles no Responsible
for heart contraction (involuntary) Striated,single nucleus,
branching , intercalated discssmooth muscles no Responsible for
involuntary movement of the GIT Non striated,spindle shap,centrally
located nucleus44 43. Skeletal muscles : 1. They are voluntary
muscles . 2. attached to bone (Skeleton) 3. Attached to the
articulating bones that form joints. Proximal , more stationary
boneDistal . More mobile45 44. Skeletal muscles produce movement by
pulling on: 1-Tendons. 2-aponeurosis. NB: Tendons are strong sheets
of connective tissue, and are identical to ligaments. Tendons
attach muscle to bone and ligaments attach bone to bone 3-Other
connective tissue structures which in turn pull on bones or other
muscles The place where a tendon attaches to the more stationary
bone is called the origin and the attachment to the more movable
bone is called the insertion. Usually the tendon origin is the more
proximal point of attachment and the insertion is the more distal.
The fleshy part of the muscle between the two bones is called the
belly or gaster46 45. There are nearly 700 skeletal muscles in the
human body. These muscles are named based on one or more of the
following criteria:1- Direction of muscle fibers, such as rectus,
transverse, oblique 2-Location, such as temporalis, tibialis
3-Size, such as maximus, minimus, brevis, longus 4-Number of
origins, such as biceps, triceps, quadriceps. 5-Site of origin and
insertion, such as brachioradialis 6-Shape, such as deltoid,
trapezius 7- Action, such as flexor, extensor, abductor, adductor47
46. For coding purpose , it is more important to know the general
location of muscles since diseases, disorders, and injuries of the
muscles are generally reported using the site of the disorder
rather than the specific muscle. For example, a muscle contracture
is reported by laterality (right or left side) and by general
region (shoulder, upper arm, forearm, hand, thigh, lower leg,
ankle, foot).48 47. Diseases and Injuries of the skeletal system 49
48. Comparison of ICD-9-CM/ICD-10-CM Musculoskeletal System Coding
(Chapter 13) ICD-9-CM (710-739) Site and Laterality Bone, joint or
muscle Multiple sites codes Bone versus Joint e.g. osteoporosis
M80, M81 Acute traumatic versus chronic or recurrent MS conditions
Chapter 13 versus Chapter 1950 49. Comparison of ICD-9-CM/ICD-10-CM
Musculoskeletal System Coding (Chapter 13) ICD-9-CM (710-739)
Pathologic #sICD-10-CM (M00-M99) Pathologic #s Acute vs. aftercare
733.1; V54.0, V54.2. Coding includes 7th digit extension for
episode of care A= Active care; D=after active treatment; others
are subsequent encounters and sequela (S) Open/closed 51 50.
Comparison of ICD-9-CM/ICD-10-CM Musculoskeletal System Coding
(Chapter 13) ICD-9-CM (710-739)ICD-10-CM (M00-M99) Osteoporosis
Site applicable if + pathologic fracture a: without pathological #
Category M81 b: with current pathological # M80 Site (of #) is
included Every patient with osteoporosis52 51. Fractures
PathologicalTraumaticRelating to a condition that is caused by or
Involves a disease process.OsteoporosisothersInfectionNeoplastic53
52. 54Injuries to the skeletal system are quite common as it is a
rigid structure. The joints are also fairly susceptible to injury
53. Fracture A break or crack in the bone caused when physical
force exerted on the bone is stronger than the bone itself55 54.
Some important definitions: Closed fracture: Bone fracture not
accompanied by a break in skin. open fracture. Fracture in which
the broken end or ends of the bone have pierced the skin.56 55.
Some important definitions: Displaced fracture: Bone break in which
the two broken ends are separated.57 56. Some important
definitions:malunion58 57. Some important definitions:nonunion59
58. Some important definitions: torus fracture. the bone with
little or no displacement at Buckling or bowing of the end and no
breakage, usually occurring in children due to softer bone
tissue.60Torus Fracture of the wrist 59. Apophyseal fracture
Avulsion fracture in which a bony prominence, such as a process or
tuberosity removed from its bone at a point of strong tendinous
attachment61 60. 62 61. Greenstick fracture Incomplete fracture In
which the bone Is bent but fractured only on the outer arc of the
bend.63 62. spiral fracture. Bone break in which the disruption of
the bone is spiral to the shaft of the bone.64 63. Monteggia's
fracture. Break in the proximal half of the ulna accompanied by A
radial dislocation of the radial head65 64. Neoplastic lesion may
results in fracture Relating to any abnormal growth of new tissue,
benign or malignant; in this case, usually amalignancy. 66 65.
Salter-Harris fracture Fractures through a growth
plate.Salter-Harris fracture67 66. To code for a pathological
fracture in ICD10-CM, the followings are necessary: 1. 2. 3.
4.Anatomic site Laterality Underlying condition Episode of care
(assigned as the seventh character extension)Next : Episode of care
(assigned as the seventh character extension) A = initial encounter
for fracture D = subsequent encounter for fracture with routine
healing G = subsequent encounter for fracture with delayed healing
K = subsequent encounter for fracture with nonunion P = subsequent
encounter for fracture with malunion S = sequel68 67. ICD 10
approach to Pathological fractures There are three subcategories
for pathological fractures in ICD-10-CMM 8 4. Pathological
fracture, not elsewhere classifiedPathological fracture in
neoplastic diseasePathological fracture in other disease69 68. By
determining the location & laterality of the pathological
fracture 2 more characters are addedM M M M M M M M M8 8 8 8 8 8 8
8 84. 4. 4. 4. 4. 4. 4. 4. 4.4 4 4 4 4 4 4 4 47 7 7 7 7 7 7 7 71 2
3 4 5 6 7 8 970 - 69. By determining the episode of care : 7th
digit is added. A = initial encounter for fracture D = subsequent
encounter for fracture with routine healing G = subsequent
encounter for fracture with delayed healing K = subsequent
encounter for fracture with nonunion P = subsequent encounter for
fracture with malunion S = sequel 71 70. example : M 8 4. 4 7 5 A72
71. NB: Sometimes when there is not enough digits seventh charter,
require placeholders so that the seventh digit extension falls to
the seventh character.Example: Code M84.48Pathological fracture,
other site, requires a seventh character to make it a complete
code; however there are only five characters currently. The
appropriate code for the initial episode of care would beM 8 4. 4 8
X AThe X must be added as a placeholder in order to have the A fall
into the seventh character field. The seventh character extender
must always remain at the 7th character. 73 72. 74 73. Disorder
characterized by bone degeneration. Osteoporosis Is caused by the
breakdown of the bony matrix without equivalent regeneration,
resulting in a weak, porous, fragile bone structure. It is the most
common type of bone disease as studies indicate that about one in
five American women over the age of 50 is affected byA bone Has
bony matrix made of protein Minerals calcium and phosphates
compoundsosteoporosis. half of these women will have a fracture of
thehip, wrist, or vertebra 75 74. Causes of osteoporosis: The
leading causes of osteoporosis are a drop in estrogen in women at
the time of menopause and a drop in testosterone in men. Other
causes include: Confinement to a bed. Chronic rheumatoid arthritis
Chronic kidney disease. Eating disorders Certain corticosteroids.76
75. 77 76. To code osteoporosis in ICD-10-CM the following is
necessary: Type of osteoporosis With or without pathological
fracture With pathological fracture - Site of fracture must be
identified Without pathological fracture Episode of care (assigned
as a seventh digit extension) A = initial encounter for fracture D
= subsequent encounter for fracture with routine healing G =
subsequent encounter for fracture with delayed healing K =
subsequent encounter for fracture with nonunion P = subsequent
encounter for fracture with malunion S = sequela (late effect)78
77. The ICD-10-CM code range for Disorders of bone density and
structure is M80M85. Osteoporosis with current pathological
fractureOsteoporosis without current pathological fractureAdult
osteomalaciaDisorder of continuity of boneOther disorders of bone
density and structure79 78. The documentation in the clinical
record will be the guide for the selection of the most appropriate
character.According to the official ICD-10-CM guidelines,
osteoporosis is a systemic condition, meaning that all bones of the
musculoskeletal system are affected. Site is not a component of the
codes under category M81, osteoporosis without current pathological
fracture. The site codes under category M80, osteoporosis with
current pathological fracture, identify the site of the fracture,
not the osteoporosis80 79. Age-related osteoporosis with current
pathological fractureright shoulderM 8 0. 0 1 1 Ainitial episode of
care Age-related osteoporosis with current pathological
fractureleft shoulder Subsequent encounter for fracture with
malunion Age-related osteoporosis with current pathological
fractureUnspecified shoulder SequelaM 8 0. 0 1 2 KM 8 0. 0 1 9 S81
80. Other osteoporosis with current pathological fractureright
shoulderM 8 0. 8 1 1 Ainitial episode of care Other osteoporosis
with current pathological fractureleft shoulder Subsequent
encounter for fracture with malunion Other osteoporosis with
current pathological fractureUnspecified shoulder SequelaM 8 0. 8 1
2 KM 8 0. 8 1 9 S82 81. osteoporosis without current pathological
fractureM8183 82. 84 83. It is the point of articulation between 2
bones as mentioned before .Joint between the sternum and the
clavicle.85 Exhibit 17 84. 86 85. Dislocations can occur in , , ,
in the joints., andas well asWhen a dislocation occurs, the joint
cant be moved. Dislocated joints often are swollen, very painful,
and visibly out of place. manipulations to reposition the bones.
medicine.a splint or sling, and rehabilitation.87 86. Strains ,
Sprains , Tearssprain It is an injury to a ligamentstrainTearIt is
an injury to either a muscle or a tendon.Tearing (part or all) of
the muscle fibers and the tendons attached to the muscle.Depending
on the severity of the injury, a strain may be a simple overstretch
of the muscle or tendon, or it can result in a partial or complete
tear.The tearing of the muscle can also damage small blood vessels,
causing local bleeding (bruising) and painSite : The most commonly
injured ligaments are in the ankle, knee, and wrist. It involve a
stretching or a tearing of this tissue.88 87. To code for
dislocations in ICD-10-CM the following is necessary 1-Anatomic
site 2-Laterality 3-Type of injury [Dislocation o Subluxation o
Sprain ] 4. Episode of care (assigned as the seventh digit
extension) A = initial encounter D = subsequent encounter S =
sequel89 88. ICD 10 approach to DislocationS S S S S S S S S S0 1 2
3 4 5 6 7 8 93. 3. 3. 3. 3. 3. 3. 3. 3. 3.90 89. We will pick up
Dislocation and sprain of joints and ligaments of shoulder girdle
S43. category By determining direction of subluxation 2 more
characters are addedS 4 3. 0 0 S 4 3. 0 1 S 4 3. 0 2 S 4 3. 0 3S 4
3. 0 8 91 90. By determining laterality and distinguishing between
subluxation and dislocation: 1 more character is addedS 4 3. 0 1 1
S 4 3. 0 1 2 S 4 3. 0 1 3 S 4 3. 0 1 4 S 4 3. 0 1 5 -S 4 3. 0 1 6
-92 91. S 4 3. 0 1 2 D93 92. 94Arthritis is a group of conditions
involving damage to the joints of the body. There are over 100
different forms of arthritis. The most common type is
osteoarthritisA common type is rheumatoid arthritis 93. 95 94. also
known as inflammatory degenerative joint disease.Causes : which can
result from trauma to the joint, infection of the joint, or age (It
affects the elderly and cannot be cured.)Symptoms: The most common
symptom of arthritis is constant pain, The pain it causes can be
debilitating and prevent one from doing any type of
activity.Pathophysiology : Osteoarthritis can affect both the
larger and smaller joints of the body, including the hands, feet,
back, hip, or knee. Osteoarthritis begins in the cartilage and
eventually leads to the two opposing bones eroding into each other,
acquired from daily wear and tear of the joint.Prevention and
treatment: It can be prevented from worsening through weight loss,
and muscle strengthening. In the very advanced stages, surgery may
be required to include joint replacement.96 95. Types of
osteoarthritis97 96. Exhibit 18 RA is chronic inflammation and
destruction of the joint tissues due to an autoimmune disorder. RA
can also affect other body systems and organs and is, therefore,
sometimes considered a systemic disease. most damage occurs to the
joint lining and cartilage, which eventually results in erosion of
two opposing bones.98 97. Rheumatoid arthritis is an autoimmune
disease that affects joints in the fingers, wrists, knees, and
elbows. The disease can lead to severe deformity within a few years
if not treated. Rheumatoid arthritis occurs mostly in people aged
20 and above. In children, the disorder can present with a skin
rash, fever, pain, disability, and limitations in daily activities
1-Joint pain and swelling2-Stiffness, especially in the morning or
after sitting for long periods 3-Fatigue. 4-Firm bumps of tissue
under the skin.99 98. Neuropathyinflammation and disfigurement of
the joints, causing compression and entrapment of nerves100 99. The
ICD-10-CM codes for osteoarthritis are found in sections M15. M19.
To code for arthritis in ICD-10-CM, the following is necessary: -
Type of osteoarthritis - primary. - secondary. - traumatic -
Laterality 101 100. osteoarthritis of knee Primary--Bilateral
Unilateral primary osteoarthritis. unspecified knee Unilateral
primary osteoarthritis Right knee Unilateral primary osteoarthritis
left kneeOsteoarthritis of knee Secondary Post-traumatic Bilateral
Unilateral post-traumatic osteoarthritisunspecified knee Unilateral
post-traumatic osteoarthritisright kneeUnilateral post-traumatic
osteoarthritisleft knee Osteoarthritis of knee Secondary Due to
other cause Bilateralunilateral secondary osteoarthritis Due to
other causeM M M M M M M M1 1 1 1 1 1 1 17. 7. 7. 7.0 1 0 1 1 1 27.
7. 7. 7.2 3 0 3 1 3 2M 1 7. 4 M 1 7. 5102
