3.2 Mention some histopatological variant of lipoma. Self Assessment
1. BONE
1.1 Disorders of the skeletal system can occur in many nutritional and endocrine disorders. Describe the morphologic appearance of osteoporosis.
1.2 The most common etiologic agents of osteomyelitis are pyogenic bacteria and Mycobacterium tuberculosis. Describe the macroscopic and microscopic appearance
of acute chronic osteomyelitis, and tuberculous osteomyelitis. 1.3 Diagnosis of bone tumors require integration of the clinical history, radiologic,
macroscopic and microscopic appearance of the tumor. Describe the macroscopic and microscopic appearance of the :
1.4 Bone-forming tumor osteoma, osteoid osteoma and osteoblastoma, and osteosarcoma.
1.5 Cartilaginous tumors osteochondroma, chondroma and chondrosarcoma.
2. JOINT
2.1 The most common disorder of the joints is degenerative joint disease. Describe some sequences in morphologic appearance of that disorder.
2.2 Gout arthritis is caused by the tissue accumulation of excessive amounts of uric acid. There are four major morphologic manifestations of gout arthritis. Describe the
four manifestation above. 2.3 The most common form of infectious arthritis are caused by bacteria. Describe the
macroscopic and microscopic appearance of acute suppurative arthritis.
3. MUSCLE
3.1 Describe the macroscopic and microscopic appearance of rhabdomyosarcoma 3.2 Describe the macroscopic and microscopic appearance of leiomyoma and
leiomyosarcoma
4. SOFT TISSUE Describe the macroscopic and microscopic appearance of soft tissue tumor :
- adipose tissue : lipoma and liposarcoma
- fibrous tissue : fibrosarcoma
Learning Resources : Robbins Basic Pathology, 7
th
ed, Kumar V, Cotran RS, Robbins SL. WB Saunders, Philadelphia, 2003, pp 755-787.
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MODULE
6
ORTHOPAEDIC PROBLEM AND ITS MANAGEMENT
Dr. dr. Elysanti, SpRad Prof. Dr. dr. Putu Astawa, SpOTK, M.Kes
AIMS:
Describe the clinical management of musculoskeletal disorders Dx, RO”, Lab. Th. medical, operative and rehabilitation
LEARNING OUTCOMES:
Describe how to: 1. Diagnosis
2. Rontgen 3. Laboratory
4. Therapy medical, operative and rehabilitation
CURRCIULUM CONTENS:
1. history taking, fundamental four and secret seven of MSD’s 2. physical examination of MSD’s
3. investigation routine and specific of MSD’s 4. modality of treatment of MSD’s
ABSTRACTS Prof. Dr.dr. Putu Astawa, SpOTK. M.Kes
The clinical management of musculoskeletal disorders consists of how to make a proper diagnosis through good anamnesis, physical examination, rontgen, and laboratory
and give the patient proper treatment with medical, operative and rehabilitation modality.
SELF DIRECTING LEARNING
Basic knowledge that must be known: 1. The procedure of musculoskeletal disorders diagnosis
2. Management of musculoskeletal disorders 3. Imaging for musculoskeletal disorders
SCENARIO
Ten years old boy came to orthopaedic clinic with main complain swollen in the right knee due to trauma 1 week ago. The swollen has already developed before trauma and
pain has already developed several months before. Patient’s bodyweight felt decrease 1 month ago. No fever.
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Learning Task: 1. From the story above, what need to be asking to the patient? Remember the secret
seven and fundamental four. 2. Make the physical examination of this patient with imagination in correlation with the
story above. 3. What is the differential diagnosis of this patient?
4. Please explain the pathogenesis from each of the differential diagnosis that has been mentioned above
5. What is the planning diagnosis that you suggest? 6. If you want to make an X-ray, how to make a good photo? Remember the rule of
two. 7. How to read an X-ray photo of bone in generally?
8. If you doubt in make a diagnosis then need a biopsy and pathological examination. How is the general pathological appearance of chronic infection, TBC and bone
malignancy? Self Assessment:
1. How to do a good anamnesa in musculoskeletal cases 2. How to do a good physical examination in musculoskeletal cases
3. What is the laboratory findings that need to be checked in musculoskeletal cases 4. How to do radiologic imaging and reading in musculoskeletal cases
5. What is the etiology of musculoskeletal cases in general
LEARNING OBJECTIVE
Describe Radiological Imaging in Musculoskeletal System
ABSTRACTS Dr. dr. Elysanti Danun, Sp Rad.
Evaluating the radiology imaging, it is important to evaluate the condition of soft tissue, bones and joint. Remember rule of two in making x-rays. So after studying the
musculoskeletal topic, the students are expected to diagnose the mormal and abnormal patient, which at least consist of :
1. Traumatic : fracture and joint disclocation 2. Infection, ex. Osteomyelitis
3. Malignancy, ex. Osteosarcoma
Learning Task
Find Radiologic term
o Systematicsm of x-ray reading o Radioscleerotic
o Radiolucent o Codmann Triangle
o Onion Shape. o Gegraphic patern
o Mooth eaten o Permeated patern
Self Assessment 1. How to know the fracture in X – Ray
2. How to know the osteomyelitis
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3. How to know the osteosarcoma
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MODULE
7
THE APPENDICULAR SKELETON
Prof. Dr. dr. Mangku Karmaya, M.Repro
AIMS:
Establish the appendicular skeleton for human movement
LEARNING OUTCOMES:
Comprehend the macroscopic aspect of appedicular skeleton
CURRICULUM CONTENTS:
1. Upper 2. Lower limb
ABSTRACTS
Both appendicular skeletons that build upper and lower limb have the similar patern. They attach at axial skeleton through girdle. Humeral joint is analog to hip joint, humery
analog to femur, elbow joint to knee, radius ulna to tibia fibula, wrist to ankle and hand to foot. Due to work load of both appendicular skeletons, joint and lower limb muscles are
stronger than upper limb. The type of joint promotes for upper limb for more free movement, pronation supination and occur inversion eversion on lower limb. The phalanges of hand
can do apposition movement compare to foot is not possible. All of the appedicular skeleton were covered by group muscles, and their type are similar.
UPPER LIMB SELF DIRECTING LEARNING
Basic knowledge that must be known: 1. The upper and lower limb. Explain the part of those bone
2. Important parts of upper and lower limb bones 3. The muscles in the regions of shoulderbuttock, fore armfemur, lower armleg,
handpedis
SCENARIO
Case 1 A15-year-old girl, while demonstrating to her friends her proficiency at standing on
her hands, suddenly went off balance and put all her body weight on her left outstretched hand. A distinctive cracking noise was heard, and he felt a suddent pain in her left shoulder
region. On examination in the emergency department, the smooth contour of her left
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shoulder was absent. The clavicle was obviously fractured, and the edge of the bony fragments could be palpated.
Learning task 1. Which part of clavicle that the fracture commonly occurs. Why?
2. What is the position of lateral and medial fragments according to muscles traction? 3. Describe all bones that joint the clavicle.
4. What is the function of clavicle?
Case 2 A 63-year-old man fell down a flight of stairs and sustained a fracture of the lower
end of the left radius. On examination the distal end of the radius was displaced posteriorly. This patient has sustained a Colles’ fracture.
Learning task 1. Why the distal end of the radius was displaced posteriorly?
2. Describe all bones that joint the tradius 3. Describe all muscles attached to the radius
LOWER LIMB Case 1
After recovery from long hospitalization, a 65-year-old woman try to walk alone. But suddenly she fell down. The doctor noted that the woman had a spontaneous fracture of the
neck of the femur . The neck fractures are common and are of two types, subcapital and trochanteric. Subcapital femoral neck fractures are particularly common in women after
menopause.
Learning task 1. Why the fractures have gender predisposition?
2. In the neck fractures the leg become shortened and pointed laterally. Why? Think about the muscles pull action.
3. Describe all mucles attached to the neck and shaft of the femur Case 2
A motocyclist try his new motorcycle in town mainroad in high speed. But he did not know the truck in front of him suddenly turn to the right. The accident could not be avoided.
After striking hard the truck the man was thrown 10 meters and landed first on his right leg. On examination in the emergency department the doctor noted fractures of the right tibia
with minimal displacement.
Learning task 1. Why the displacement was minimal?
2. Why the fracture of the shaft of the tibia are more frequent compare to fibula? 3. What muscles are attached to tibia?
Self assessment 1. Compare the upper and lower limb
2. Identify the important parts of upper and lower limb bones 3. Identify the muscles in the regions of shoulderbuttock, fore armfemur, lower
armleg, handpedis
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MODULE
8
BONE FRACTURE
dr. Wien Aryana, SpOT
AIMS:
Establish tentative diagnosis, provide initial management andor refer patient with: Fracture and dislocation in child and adult.
LEARNING OUTCOMES:
Establish tentative diagnosis, provide initial management andor refer patient with: Fracture and dislocation in child and adult.
CURRICULUM CONTENTS:
1. Bone healing 2. Diagnosis, provide initial management andor refer patient with: Fracture and
dislocation in child and adult.
ABSTRACTS
A tentative diagnosis fracture is a break in the structural continuity of bone. It may be no more than a crack, a crumpling or a splintering of the cortex; more often the break is
complete and the bone fragments are displaced. Most fractures are caused by sudden and excessive force, which may be tapping,
crushing, bending, twisting or pulling. The process of fracture repair varies according to the type of bone involved and the amount of movement at the fracture site.
The specific aims of fracture treatment are: to relieve pain, to obtain and maintain satisfactory position of the fracture fragment, to allow and if necessary to encourage bony
union; to restore optimum function not only in the fracture limb or spine but also in the patient as a person.
There are three degrees of joint stability: occult joint instability, subluxation in which the joint surfaces have lost their normal relationship but still retain considerable contact;
dislocation in which the joint surfaces have completely lost contact. The general principles of treatment for dislocations and subluxations: in order to restore
normal congruity to the joint surfaces, perfect reduction of dislocations and subluxations must be achieved, either by closed manipulation or, when necessary, by open reduction.
SELF DIRECTING LEARNING
Basic knowledge that must be known: 1. The type of fracture and healing process
2. Fracture in adult and children 3. Management of fracture
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SCENARIO
Male 30 years old, came to our hospital with painful, swollen on he left thigh and difficulty to move his leg after traffic accident. He was motor cyclist and hit by a car. On
physical examination: shortening of his left lower leg and false movement found. 1. What symptom and sign you find?
2. Which one is the probably symptom and sign for fracture? 3. Which one is the significant full blown symptom and sign for fracture?
Learning Task 1. How fractures happen?
2. Types of fracture 3. How fractures are displaced?
4. Fracture healing
Self Assessment 1. Describe about normal healing of fracture
2. Describe about abnormal healing of fracture
LEARNING OUTCOME
Establish tentative diagnosis, provide initial management andor refer patient with: Fracture and dislocation in child and adult.
o Fracture in adult
SCENARIO
Male 25 years old, came to our hospital with painfull on he left thigh and difficulty to move his leg after traffic accident. He was motor cyclist and hit by a car.
On physical examination: shortening of his left lower leg and false movement found. 1. What is your assessment for this patient?
2. How to manage the patient? Learning Task
1. The special features of fractures and dislocation in adult and children 2. The general principles of fracture treatment
3. How to diagnosis of fracture and associated injuries
Self Assessment 1. Describe the special features of fractures and dislocation in adult
2. Explain the general principles of fracture treatment 3. How to diagnosis of fracture and associated injuries
4. Describe 3 degree of joint histability
LEARNING OBJECTIVE
Establish tentative diagnosis, provide initial management andor refer patient with: Fracture and dislocation in child and adult.
o Fracture in children
SCENARIO
Male, 3 years old, came to emergency unit with painfull on the right elbow and difficulty to movement his elbow after traffic accident. On physical examination; swelling of
right elbow. 1. What is your assessment for this patient?
2. How to manage the patient? Learning Task
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1. The specific methods of treatment of closed fracture 2. The complication of fractures and complication of fracture treatment
3. Explain about 3 degree of joint instability
Self Assessment 1. Describe the special features of fractures and dislocation in children
2. Explain the specific methods of treatment of closed fracture 3. Describe about the complication of fractures
4. Describe about the complication of fracture treatment
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MODULE
9
BONE JOINT, TENDONS AND LIGAMENTS
Prof. Dr.dr. Mangku Karmaya, M.Repro
AIMS:
Describe normal structure and function of Joints and articular cartilage and.
LEARNING OUTCOMES:
Apply its concepts and principles in the approach of patient with common arthritis and related inflammation infection
CURRICULUM CONTENTS:
1. cartilage of joint 2. sinovium and sinovial fluid
3. function of Joint
ABSTRACTS
A joint is an articulation, the place of union or junction between two or more rigid components bone, cartilages, or even parts of the same bone. Joints show variety of form
and function. Some joints have no movement; others allow only slight movement, and some are freely movable.
There are three types of joint according to the manner of material by which the articulating bones are united: 1 fibrous joints are united by fibrous tissue. This type are
found as syndesmosis where a sheet of fibrous tissue, either a ligament or fibrous membrane, interosseous membrane in the forearm between radius and ulna and
gomphosis or dentoalveolar syndesmosis between the root of the tooth and the alveolar process. 2 cartilaginous joints are united by cartilage or fibrocartilage and 3 synovial
joints, the most common type of joint, that the articulating surfaces are covered with cartilage and united by a fibrous capsule.
Distinguishing features of a synovial joint are, a joint cavity, articular cartilage that cover the bone end, and articular or joint capsule fibrous capsule lined with synovial
membrane that enclose articulating surfaces and joint cavity. There are several types of synovial joint: 1 hinge joint uniaxial: permit flexion and extension only eg., elbow joint, 2
pivot joint uniaxial: allow rotation, a round process of bone fits into a bony ligamentous socket e.g., atlantooccipital joint between atlas C1 and axisC2, 3 saddle joint biaxial:
are shape like a saddle; i.e., they are concave and convex where bones articulate; 4 condyloid joints biaxial: permit flexion and extension, abduction and adduction, and
circumduction; eg., metacarpophalangeal joints or digits; 5 plane joints permit gliding or sliding movement e.g., acromioclavicular joint and 6 ball and socket joints multiaxial:
permit movement in several axes: flexion-extension, abductuction-adduction, medial and lateral rotation and circumduction, where a rounded head fits into a concavity
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SELF DIRECTING LEARNING
Basic knowledge that must be known: 1. Classification of joints and its structures
2. Parts of synovial joint 3. The anatomy of ligament, tendon, aponeurosis, synovial tendon sheaths and bursae
and their functions 4. Intra and extra articular ligaments
SCENARIO : Case 1
A 60 year-old-woman fell down the stairs and was admitted to the emergency department with severe right shoulder pain. On examination, the patient was sitting up with
her right arm by her side and her right elbow joint supported by the left hand. Inspection of the right shoulder showed loss of the normal rounded curvature and evidence of slight
swelling below the right clavicle. Any atempt at active or passive movement of the shoulder was stop by severe pain in the shoulder. A diagnosis of dislocation of he right shoulder joint
was made.
Learning task 1. Why the shoulder joint prone to dislocation?
2. Why the downward dislocation more frequent? 3. Describe the shoulder joint, its movement and the muscles involved.
Case 2
A father seeing his 3-year-old son playing in the garden, ran up and pick him up by both hands and swung him around in a circle. The child’s enjoyment suddenly urned to
tearsand he said left elbow hurt. On examination, the child held his left elbow joint hemiflexed and his forearm pronated.
Learning task 1. What was really happen to the child’s elbow?
2. Why the elbow position hemiflexed and the fore arm pronated? 3. Describe the elbow joint the bone, type, capsule, ligaments, synovial membrane.
Case 3 A medical student, while playing football, collided with another player and fell to the
ground. As he fell the right knee, which was taking the weight of his body, was partially flexed, the femur rotatede medially, and the leg abducted on the thigh. A sudden pain was
felt in the right knee joint, and he was unable to extend it. The student was diagnosed as having a torn medial meniscus of the kenee joint.
Learning task 1. What is meniscus? What is discus disc? What are their differences?
2. What structures involved in forming the knee joint? 3. What kind of movement in the knee joint and what muscles involved in the
movement? 4. Compare the knee joint and elbow joint.
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Self assessment 1. Describe the classification of joints and its structures
2. Describe the six major types of synovial joints and give examples for each type and their possible movements
3. Identify the parts of synovial joint 4. Describe the joint of vertebral column
5. Compare the joints of upper and lower limb
AIMS:
Describe normal structure and function of Tendons and ligaments.
LEARNING OUTCOMES:
Apply its concepts and principles in the approach of patient with musculoskeletal disorders such as tendinitis
CURRICULUM CONTENTS:
1. Tendon 2. Ligament
ABSTRACTS OF LECTURES Structure and Function of Ligaments and Tendons
Ligaments and tendons are soft collagenous tissues. Ligaments connect bone to bone and tendons connect muscles to bone. Ligaments and tendons play a significant role
in musculoskeletal biomechanics. They represent an important area of orthopaedic treatment for which many challenges for repair remain. A good deal of these challenges has
to do with restoring the normal mechanical function of these tissues. Again, as with all biological tissues, ligaments and tendons have a hierarchical structure that affects their
mechanical behavior. In addition, ligaments and tendons can adapt to changes in their mechanical environment due to injury, disease or exercise. Thus, ligaments and tendons are
another example of the structure-function concept and the mechanically mediated adaptation concept that permeate this biomechanics course. In this section, we will review
aspects of ligament and tendon structure, function and adaptation. These notes follow very closely Chapter 6 on Structure and Function of Tendons and Ligaments from your text.
We start out again emphasizing those ligaments and tendons have a hierarchical structure. One schematic of this hierarchical structure is taken from your text, and is a very
famous schematic from Kasterlic:
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The largest structure in the above schematic is the tendon shown or the ligament itselt. The ligament or tendon then is split into smaller entities called fascicles. The fascicle
contains the basic fibril of the ligament or tendon, and the fibroblasts, which are the biological cells that produce the ligament or tendon. There is a structural characteristic at
this level that plays a significant role in the mechanics of ligaments and tendons: the crimp of the fibril. The crimp is the waviness of the fibril; we will see that this contributes
significantly to the nonlinear stress strain relationship for ligaments and tendons and indeed for bascially all soft collagenous tissues.
SCENARIO
Case 1 A 54-year-old man was told by his physician to reduce his weight. He was prescribed
a diet and was advised to exercise more. One morning while jogging, he heard a sharp snap and felt a sudden pain in his right lower calf. Onaxamination in the emergency
department, physician noted that the upper part of the right calf was swollen and a gap was apparent between the swelling and the heel. A diagnosis of rupture of the right Achilles
tendon was made.
Learning task 1. Why there was a gap apparent between the swelling and the heel?
2. Describe the anatomical and physiological aspects of Achilles tendon. Case 2
A 27-year-old woma was running across some rough ground when the stumbled and overinverted her left foot. On examination in the emergency department of the local hospital,
the lateral side of the left ankle was tender and swollen. A small area of hgreat tendernes was found below and in front of the lateral m,alleolus. X-ray exmination on the ankle joint
was negative. A diagnosis of sprain of the left ankle was made.
Learning task 1. Why overinverted can cause sprain on the lateral side?
2. Describe the ankle joint, the muscles and the movements. 3. What structures as a stabilisator of ankle joint?
Case 3 A worker complained pain on his right elbow after doing painting. There was a
swelling on the joint and become more pain after moving the elbow and grasping. On examination the doctor suspect a tendon injured.
Learing task 1. What tendon supposed to be injured? Why?
2. Describe the elbow joint, its movements and its muscles. Self assessment
1. Describe the differences between ligament, tendon, aponeurosis, synovial tendon sheaths and bursae and their functions
2. Describe the intra and extra articular ligaments 3. Describe some clinical aspects of the ligaments, tendon, aponeurosis, synovial
tendon sheath and bursae.
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MODULE
10
BONE AND IMUNOLOGY DISORDERS OSTEOARTHRITIS AND GOUT ARTHRITIS
Prof. Dr. dr. Tjok Raka Putra, Sp.PD
AIMS:
Establish tentative diagnosis, provide initial management andor refer patient with imunologis disorder.
LEARNING OUTCOMES:
Establish tentative diagnosis, provide initial management andor refer patient with osteoarthritis
CURRICULUM CONTENTS:
1. Osteoarthritis 2. Gout
ABSTRACTS
The new definition Osteoarthritis OA is a result from mechanic and biochemistry phenomenon where imbalance between degradation and synthesis from chondrosit
cartilage and matrix extracellular and subchondral bone. OA is a form of arthritis that common happened in human. Clinically OA is characterized with joint stiffness, pain and
motion disorder, which in late state can develop deformity and immobilization. Osteophyte in cartilage can be found in radiographic findings. Estimation 10-30 of OA patients will
become permanent disable; therefore OA is the main cause of chronic dysfunction worldwide. Treatment of OA until now is still unsatisfied, and the goal treatment is to reduce
pain and disabilities.
SELF DIRECTING LEARNING
Basic knowledge that must be known: 1. Diagnosis of Osteoarthritis
2. Management of osteoarthritis 3. Diagnosis of gout arthritis
4. Management of gout arthritis
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SCENARIO
A 57 year old woman government servant, a Balinese pensioner came to hospital with main complaint swelling of right knee since 2 months ago. She also complains pain
while moving around. She has the relapse during religious occasion in her village. Her weight is 67kg and height 156cm. At the moment, she is active as a Hindu priest.
1. What are other things that have to be asked in patient with swelling and pain in the knee?
2. What associate factors those need to be asked? 3. What other risk factors should be asked in this patient?
1. What other physical examination should be find in this patient? 4. What are the diagnosis criteria in this patient?
5. What is the general management in this patient? 6. What is the medication should be given in this patient?
7. How do you educate this patient? 8. When do we refer this patient to expertise? And what expertise?
Learning Task 1. Joint Anatomy
2. Joint disorder in Osteoarthritis patient 3. Pathogenesis of Osteoarthritis
4. Diagnosis criteria in Osteoarthritis 5. Management of Osteoarthritis
Self Assessment: 1. Please state types and etiology of OA
2. Please state pathogenesis of OA 3. What are the pathology found in OA
4. What are the diagnostic criteria in OA 5. What are the complications in OA
LEARNING OBJECTIVE Establish tentative diagnosis, provide initial management andor refer patient with:
Gouty arthritisPseudo Gout
ABSTRACTS
Gouty arthritis is a disease of uric acid metabolism disorder, characterized by hyperuricemia and uric acid crystal deposits in joint, predominantly at big toe. Gouty arthritis
is a group of heterogenic disease caused by deposition of uric monosodium crystal in tissue or supersaturation of uric acid in extracellular fluid. Gouty is a disease caused by uric acid
metabolism, manifested by gouty arthritis, uric acid accumulation in tissue, uric nephropaty, uric acid stone in kidney. Most of gouty arthritis common in men 90, with peak of acute
attack in fifth decade of life, in woman it commonly occured after menopause. Management of gouty arthritis patient should be comprehensive and continuous. Basic principle of the
management is normal uric acid serum regulation.
SCENARIO
A 45 year old Balinese Male, with height 170 cm, weight 65 kg, complaint pain and swelling in his left big toe since yesterday. Two day ago, he didn´t complaint any thing and
he just played football in renon field. He had the same complaint before but never this worst. Patient feels dizzy and malaise. He had history of high uric acid level but 3 months ago the
level was 6.5 mg. He has no take medication.
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Learning Task: 1. What should you ask to the patient if the chief complaint is swelling at big toe?
2. What other complaints that you should ask to this patient? 3. What are the risk factors in this patient?
4. What are the physical examination general and specific that you should look in
this patient? 5. How to make proper diagnosis in this patient?
6. What is the management in general? 7. What medication should be given to this patient?
8. What other education should be given to this patient? 9. When this patient should be referred to expertise? To what expertise?
Self Assessment: 1. What is hyperuricemia?
2. What is the pathologic manifestation of hyperurecemia? 3. What is the pathogenesis of gouty arthritis?
4. What are the diagnosis criteria of gouty arthritis? 5. What is the gold standard to diagnose gouty arthritis?
6. What are the complications of gouty arthritis? 7. What is the management of gouty arthritis?
8. What medication should be given in acute gouty arthritis? 9. What is the management of intercritical and chronic gouty arthritis?
10. What is the diet in gouty arthritis patient?
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MODULE
11
SKELETAL MUSCLES
dr. I.G Kamasan Nym Arijana, M.Si. Med
AIMS:
Describe normal of microscopic structure and function of skeletal muscles.
LEARNING OUTCOMES:
Apply its concepts and principles in the approach of patient with musculoskeletal disorders such as degenerative disease of muscle Duchene, Becker
CURRICULUM CONTENTS:
Microscopic of Skeletal muscle
ABSTRACTS Histology of Muscle
The muscle cells are mesodermal origin. Their differentiation occurs mainly by gradual process of lengthening. Muscle tissue is responsible for body movements. Three
types of muscle tissue may be distinguished on the basic of morphologic and fungtional characteristic. Smooth muscle consists of collections of fusiform cells with light microscope
do not show striation. Striated skeletal muscle is composed of bundles of very long cylindric multinucleated cells that present cross-striation. Cardiac muscle composed of elongated or
branched cells that run parallel each other and end to end contact are the intercalated disks and it contraction is voluntary, vigorous and rhythmic.
Organization of striated muscle Dense connective tissue surrounding the entire muscle called the epimysium and
extend inward surrounding bundles of muscle are called perimysium and delicate layer of connective tissue surrounding the fiber called endomysium.
The blood vessels penetrate into the muscle runs between and parallel to the muscle fibers. As observed with the light microscope, longitudinally sectioned muscle fibers when stained
with hematoxylin and eosin show darker bands are called A band and lighter band are called I band. Each I band is bisected by dark tranverse lines, the Z line. The smallest repetitive
subunit of the contractile apparatus is called sarcomere extend from Z to Z.
The sarcoplasm of each fiber is filled with long cylindric filamentous bundles called myofibrils and composed of end to end chain-like arrangement of sarcomeres. The
sarcomere are composed of thick the myosin and thin the actin filament. The thick filaments occupy the A band the central of sarcomere and the thin filaments run between
and parallel to the thick ones and have one end attached to Z line.
The striated muscle fibers contain at least four main proteins: actin, tropomyosin, troponin and myosin. Troponin is a complex of 3 subunits: TnT attached to tropomyosin,
TnC which binds calsium ions and TnI which inhibits the actin and myosin interaction .
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Myosin can be cleaved into two fragments, light meromyosin and heavy meromyosin. Analysis of thin section of striated muscle show the present of crossbridges between thin
and thick filament.The head of the myosin, the ATPase head are considered to be directly involved in transduction chemical into mechanical energy for muscle contraction.
Organization of cardiac muscle Mature cardiac cell exhibit a crossstriated banding patern which centrally nucleus
identical to that skeletal muscle and distinguish by the present of intercalated disk a junctional complexs between adjacent cardiac muscle. Cells within a chain often bifurcate or
branch and bind to cell adjacent chains. Smooth muscle is composed of long spindlelike cells, each cell possesses centrally located
nucleus. In bundles of smooth muscle, the fusiform cells overlap one another along their length. The bundles normally arranged into layers with cells in adjacent layers usually lying
at right angles to each other.
SELF DIRECTING LEARNING
Basic knowledge that must be known: 1. Microscopic view of muscle cell
2. Typre of muscle cell 3. The component of cell relate to muscle contraction
SCENARIO
A 50-year-old man came to the clinic because of the asymetry of his leg: the left leg being much smaller than the right one. Five months earlier, he had an accident with fracture
of his left leg tibial bone and he refused to get an operation. Until now, he has been using a crutch to support his left leg during walking. The doctor diagnosed him to suffer from
disuse atrophy.
Learning Task: 1. What has happened to the structure of his left skeletal muscle?
2. Describe the microscopic structure of skeletal muscle 3. Differentiate the skeletal muscle from cardiac and smooth muscles
4. Describe the structural organization of myofibrils and sarcomere
Self Assessment: 1. Can you tell me all cell structure that involved in contraction?
2. Please differentiate the three kind of muscle cell? 3. Can you tell me the ultrastructure of actin and myosin?
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MODULE
12
MUSCLE CONTRACTION AS MOVEMENT TRIGGER
Prof. Dr.dr. I Putu Gede Adiatmika, M.Kes
AIMS:
Describe bioelectric of excitation and muscle contraction.
LEARNING OUTCOMES:
Apply its concepts and principles in the approach of patient with musculoskeletal disorders
CURRICULUM CONTENTS:
1. Action potential 2. Muscle contraction
3. Excitation contraction process
ABSTRACT
Human movement is occur under spesific stimulation. Proper stimulus will excite the nerve to generate an action potential within nerve including axon. Action potential is affected
by sodium and potassium exchange between extracelular and intracellular fluid, permeability of membrane and membrane threshold. Every stimulation will drive electrolyte
to move pass the membrane and will increase the membrane potential to be action potential. Action potential stage consist of depolarization and repolarization. All the process
of action potential refers to all-or-nothing principle. Action potential will deliver along axon to the muscles through neuromuscular junction using neurotransmitter called acetylcholine.
Action potential will spread into the muscle through motor end plate, sarcolemma, t-tubule and cisternae. The end result of this process is release of calcium ions to the filaments.
Calcium from cisternae will stimulate sliding filamen mechanism where actin and miosin acttach each other. This process need energy that is provided from anaerobic or aerobic
metabolism and promote contraction. Mechanism of muscle contraction is similar to both skeletal and smooth muscles. The differences of them are time of contraction, energy
consumed, source of calcium ion and excitation-contraction coupling.
SELF DIRECTING LEARNING
Basic knowledge that must be known: 1. Action potential and its components
2. Process of muscle contraction 3. Transfer impus from neuron to cell
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SCENARIO
Case 1 Mr X, 45 years old, brought to emergency unit cause of traffic accident, and the
motor cycle hit his back. On physycal examination, he could not move his lower back was with the chief complaint of unable to move his lower leg.
Learning Task: 1. Identify the problem of those patients?
2. What did the cause and source of paralyze? 3. Why stimulus from the brain couldn’t move the lower leg?
4. Explain the process of action potential within the axon
Case 2 On marathon race, one athlete was falling down during the racing and scream that
his left calf was suffer from cramp. He felt very pain on the legs and asked someone to stretch the legs. The therapist sprayed chlorethyl and massaged the calf. The others gave
the athlete an isotonic liquid, too.
Learning task: 1. Please explain why the athlete suffers from cramp?
2. What is happen of contraction relaxation process within his calf muscles? 3. Identify any factors that affect to contraction process?
4. What is the important process within muscle cell that cause contraction? 5. What the role of electrolit and energy during racing?
6. What type of contraction that able to move the legs during race?
Case 3 One patient came to emergency department with the chief complaint of open wound
on the lower arm and must be stitched. The patient cried and asked for anesthesia from the doctor. During the stichting, the patient looked happy and asked the doctor what happen to
his wound and why he didn’t feel pain?
Learning Task: 1. Please explain the role of anesthesia in that case?
2. Which one of the neuromuscular components that was blocked? 3. Explain several substances that affect to neuromuscular junction?
Self Assessment: 1. Describe distribution of ions surrounding the cell membrane and concentration of
various ion to tissue electric arrangement, transport ion through Na-K pump and resting potential membrane.
2. Describe the stage of action potentials on the neuromuscular and its response. Identify resting, depolarization and repolarization stage.
3. Describe the propagation of action potential on nerve. Explain the principle of “all or none law” or “All-or-Nothing Principle”.
4. Describe general mechanism of muscle contraction or “sliding filament theory” step by step from excitation to contraction.
5. Describe the source of energy for muscle contraction. 6. Describe the characteristics of whole muscle contraction such as isotonic – isometric,
slow – fast fibers, motor unit, multiple fiber – frequency summation which can lead tetanization, muscle fatigue, atrophy – hypertrophy.
7. Describe the transfer impulse process from nerve to muscle
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8. Describe the excitation contraction process from nerve to muscles
MODULE
13
MUSCLE AND DEGENERATIVE DISORDERS
dr. Ni Made Susilawati, SpS
AIMS:
Establish tentative diagnosis, provide initial management andor refer patient with Degenerative disorders.
LEARNING OUTCOMES:
Establish tentative diagnosis, provide initial management andor refer patient with Duchene and Becker Muscular dystrophy
CURRICULUM CONTENTS:
Duchene and Becker Muscular dystrophy
ABSTRACTS OF LECTURES
Dystrophy Muscular Progressive DMP is a neuromuscular disease which attacks the muscle organs. This disease is caused by x-linked recessive. The first symptoms that
occurred is when the patient is 2 year old. The patient shows Gower Sign and waddling gait sign. The muscle weakness usually can be seen in the proximal muscles.
In the laboratory findings, there will be slight increase in CPK enzyme. The progressivity of this disease occurs fast, and the patient died at the age of 15 or 40,
depends on the type of DMP.
SELF DIRECTING LEARNING
Basic knowledge that must be known: 1. Diagnosis of Duchene and Becker Muscular dystrophy
2. Management of Duchene and Becker Muscular dystrophy
SCENARIO
The surveillance team AFP health department of Bali Province in Bangli found 2 boys at the age of 6 and 12, suffering from paralisi in 4 extremities which started from lower
extremities to the upper extremities. This started gradually when they were 3 year old. Their sister doesn’t suffer from this condition.
When the patients lie down and want to get up, they showed as if they were climbing and can’t stand spontaneously. This complain doesn’t followed by sensibility disorder such
as numbness or tingling sensation. Their calf muscle looks bigger; they walked like duck, cognitive function impaired. No history of fever or neck injury was found in these patients
before having this complain.
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Learning Task: 1. What’s the problem found in the scenario above?
2. What’s the differential diagnosis and what’s the most probable diagnosis? 3. Could you explain the pathogenesis of this disease?
4. Could you explain in detail, the clinical diagnostic of this patient? 5. What do you expect from the physical examination in this patient?
6. What other laboratory would like to perform in this patient? 7. How do you manage this patient?
8. When do you refer this patient?
Self Assessment: 1. What is the genetic characteristic and how it can be passed in their kids?
2. Please explain the clinical signs and symptoms in DMP patient and types of DMP? 3. What other test needed to help the diagnosis?
4. What is the early stage management in this patient and how to suppress the
progressivity of this disease? 5. How is the prognosis in DMP patients based on the type?
RHEMATIC NON ARTHRICULAR dr. Kambayana, Sp.PD
Will be delivered later – on scheduled
MODULE
14
DEGENERATIVE DISORDERS OF SPINE
dr. K.G. Mulyadi Ridia, SpOT K dr. K. Suyasa, Sp.B, Sp.OT K
LEARNING OBJECTIVE
Establish tentative diagnosis, provide initial management andor refer patient with Degenerative disorders of spine.
CURICULIM CONTENT
1. Low Back Pain LBP 2. Neck Pain
ABSTRACTS Dr. K.G. Mulyadi Ridia, SpOT K
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Degenerative disorders in the spine, includes two interrelated condition: intervertebral disc joint Degenerative disc disorders and posterior facet joint degenerative
joint disorders. Both condition represent an exaggeration of normal aging process, and may be aggravated by injury, deformity, and pre – existing disorders of the spine. The
resultant LBP is the most common of symptoms
The interrelated degenerative process in the spine is best considered under the heading of disc degenerative, segmental instability, segmental hyperextension, segmental
narrowing, and herniation of the disc. The treatment of patients with degeneration disorders in the spine is base in the following aims:
1. To alleviate pain 2. To help the patient understand the nature of the disorders
3. To provide psychological support 4. To strengthen weak trunk muscles
5. To improve function 6. To rehabilitate the individual patient
The methods of treatment are: Psychological consideration, therapeutic drug, bed rest, orthopaedic apparatus, appliances, physical therapy, spinal manipulation, chemo
nucleolysis, surgical apparatus, and rehabilitation.
SELF DIRECTING LEARNING
Basic knowledge that must be known: 1. Diagnosis of Low Back Pain and Neck Pain
2. Management of Low Back Pain and neck Pain
SCENARIO
55 year old male, automobile mechanic, ex weight lifter, complained back pain since 5 years ago, especially after working, and sitting for long time. Patient also felt morning
stiffness of her back. At 25 year old, patient had back pain referred to his buttocks and right leg.
Learning Task: 1. How do you do complete anamnesis of the patient with back pain and neck pain?
2. How do you do physical examination in back pain patient and neck pain ? 3. What is the predisposing factor in back pain amd meck pain patient?
4. What is the management of back pain and neck painpatient? 5. What is your advice for those patient?
Self Assessment: 1. Please draw the anatomical structure of spine
2. What are the structures in the lumbal area that might cause back pain? 3. What are the structures in the lumbal area that might cause neck pain?
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MODULE 15
ANATOMY OF MUSCULOSKELETAL DS T e a m
AIMS: LEARNING OUTCOMES:
CURRICULUM CONTENTS: PROCEDURAL OF CLINICAL SKILL:
MODULE 16
HISTOLOGY OF BONE, CARTILAGE, MUSCLE
Team
AIMS:
To increase understanding about bone, cartilage and muscle
PROCEDURAL OF CLINICAL SKILL:
Material :
1. Microscope 2. Histological preparat about bone, cartilage and muscle
a. Bone : -
Intra membraneous ossification -
Endochondral Ossification -
Compact lamellar bone -
Woven bone b. Cartilage :
- Hyaline cartilage
- Elastic cartilage
- Fibrocartilage
c. Muscle :
Udayana University Faculty of Medicine,DME
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- Cardiac muscle
- Smooth muscle
- Skeletal muscle
MODULE 17
PHYSIOLOGY OF MUSCLE CONTRACTION MUSCLE STRENGTH CONTRACTION
Team
AIMS:
1. To compare steady state work and fatigue related work 2. To comprehend the effect of blood supply disturbation, rest and massage to the
fingers muscles work
MATERIAL:
1. Kimograf SET 2. Manset spigmomanometer.
3. Ergograf 4. Metronom
PROCEDURAL OF CLINICAL SKILL : Steady state work
1. Set all the equipment as shown at the picture on the left.
2. While recorded, do one contraction every 4 second according to
Metronom’s sound 120 second minutes about 12 round of tromol.
3. After each contraction, put off your fingers from the trigger, so the trigger
will back to the initial position.
Fatigue related work
1. Blood supply disturbance: 1.1 Apply the sphigmomanometer’s manset on the same student’s upper
arm. 1.2 Before test, do several exercises of blood occlusion by pump the manset
immediately until the tester can’t feel the pulse of artery radialis. 1.3 On the same position, please do 12 contractions without occlusion every
4 second. 1.4 While continue tromol rotation, on the 13
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contraction occlusion is started by pump the manset. The student continues his contraction.
1.5 Put the sign on the curve when the pulse rate disappeared.
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1.6 After complete fatigue, decrease the blood pressure, so the blood circulation returns to normal. The student still continues his contraction.
1.7 In the same frequention, please continue the contraction and recording until the effect of blood occlusion is gone.
2 Effect of rest and massage: 2.1 Please use another student for the next test.
2.2 Set load of ergograf at the maximal position. 2.3 Do the contraction every 1 second and stop when get on complete fatigue
and stop tromol rotation. 2.4 Take a rest for 2 minutes dan put the hand on the table.
2.5 Slide the tromol manually about 2 cm and stard the rotation. Continue the contraction as previously until complete fatigue.
2.6 Take a rest for 2 minutes and do a massage on the arm of sample. 2.7 Slide the tromol, and do the similar contraction as on 2.5.
2.8 Compare both recorded of contraction only and contraction with massage.
3. Pain, color and temperature: 3.1 Do the test with new student.
3.2 Put the manset on right upper arm and give maximal load. The result will show little deviation on the tromol.
3.3 While contraction, please observe the temperature and colour of lower arm’s skin of sample.
3.4 Do the contraction every 1 second and blood occlusion until complete fatigue or painful.
3.5 Stop the occlusion when the sample feels painful. Observe the colour and temperature of lower arm’s skin.
MODULE 18
PATHOLOGY ANATOMY OF MUSCULOSKELETAL DS
Team
AIMS: LEARNING OUTCOMES:
CURRICULUM CONTENTS: PROCEDURAL OF CLINICAL SKILL:
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MODULE 19
PHYSICAL DIAGNOSTICS OF MUSCULOSKELETAL DS
Team
AIMS: LEARNING OUTCOMES:
CURRICULUM CONTENTS: PROCEDURAL OF CLINICAL SKILL:
MODULE
20
MID – TERM TEST Topics : Anatomy of Bone and Muscle
Student will be assessed using pcture of bone and muscle. The picture are provided and the student must give the name of
bones or muscles acoording to the pointer on the picture
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MODULE
21
NEOPLASM OF SOFT TISSUE BONE BENIGN
Dr. Eka W, Sp.OT
AIMS:
Establish tentative diagnosis, provide initial management andor refer patient with various soft tissues tumors and tumor-like lesion and benign neoplasm
LEARNING OUTCOMES:
Establish tentative diagnosis, provide initial management andor refer patient with various soft tissues tumors and tumor-like lesion and benign neoplasm
CURRICULUM CONTENTS: 1. soft tissues tumors and tumor-like lesion and
2. Benign neoplasm a. Osteochondrome
