Musculoskeletal Tayang Semester IV Tayang 22 Pebruari FIX

Study Guide Musculoskeletal System and Connective Tissue Disorders
Preface
Musculoskeletal system is one of the systems among all system in the body. This
system has a major role in human movement and consists of bones, muscles, joints,
tendons and ligaments including the neurovascular within the system. The knowledge of
musculoskeletal system very useful to determine the normal condition and can be used to
explain pathological concept of many disorders as a whole system. There several diseases
in this system such as development disorders, infections, metabolism, neoplasm,
degenarative and weakness of muscles. Most of the diseases can be treated as soon as
possible through holistic approach related to medical ethics and informed consent due to
patient’s satisfaction.
Musculoskeletal system is explain the whole body and it's concept as a basic
concept for the other block. That is why this block is put in advance. Some concept will be
studied again or will be used for the other block.
Musculoskeletal system and disorders will be studied based on case as a trigger.
The case is one of examples of musculoskeletal disorders that are commonly finding the
real situation. It’s needed comprehensive approach to understand this block base on basic
knowledge, clinical and rehabilitation. Hopefully this book will be used as a trigger to study
the core of musculoskeletal system and disorders and can be the basic concept to study the
others especially in special study and special topics.
Best regards
Planners
Faculty of MedicineUdayanaUniversity, MEU 1

Introduction
Movement is very important in human life. Everyone should move as an adaptation to the
entire environment even external or internal. Movement is generated by a specific
stimulation. Proper stimulus will be processed through central and peripheral nerves system
and deliver to muscles by axon and neuromuscular junction. The muscle will contract to pull
the bone that is observed as a movement.
To get the optimum movement, there are many aspects should be considered such as
bones, joints, ligaments, tendons, muscles and nerves. They all work together in a complex
coordination to generate a movement according to the stimulus. This guide book will
encourage all the students to comprehend all the topics through lecture, small group
discussion, individual learning, student project and clinical skill. Student should know about
bones and muscles since its developed, location, function and its disorders.
Disorder of musculoskeletal system could be as result of several condition such as
development, metabolism, trauma, infection, degenerative or neoplasm. Any type of
problems will need different approach of treatment such medical, operation, pharmacology
and rehabilitation. Understanding of musculoskeletal can be used in phorensic aspect and
for many purposes. The student comprehends all disorder as in real situation, so this guide
book will provide some cases as a trigger for discussion. So, active participation of student
is the most important aspect in learning by doing process, because all the topics should be
discussed in small group under supervision of facilitator.
Lecturers who give a lecture in the class just give the student the concepts of every topics,
and the student should explore and study insight under guidance of learning task and self
assessment. The succesfull of this block is depending on your active participation in teching
learning process.
See you ….
Udayana University Faculty of Medicine,DME 2

Contents
1. Preface …………………………………………………………………..1
2. Contents ………………………………………………………………….3
3. Contributors ……………………………………………………………
a. Planners ………………………………………………………….4
b. Lectures ………………………………………………………….4
c. Facilitators ……………………………………………………….5
4. Time Table Regular Class .…………………………………………….6
5. Time Table English Class ………………………………………………6
6. Students Meeting Representatives …………………………………..10
7. Student Project .................................................................................10
8. Assessment ……………………………………………………………..10
9. Learning Programme …………………………………………………..11
10. References ………………………………………………………………63

Team of Musculoskeletal
System and Disorders
Planners and Resource Persons
No Name Department Phone
1 Prof.Dr. dr. Putu Astawa, Sp.BO, M.Kes Surgery 0811392123

2 Prof. Dr. dr. I Putu Gede Adiatmika, M.Kes Physiology 08123811019
3 Prof.Dr.dr. N. Mangku Karmaya, M.Repro Anatomy 0811387105
4 dr. I G Kamasan Nym Arijana, M.Si, Med Histology 08124665966
5 Dr. dr. Ni Made Linawati, MSi Histology 03618617765
6 dr. I Gusti Ayu Sri Mahendra Dewi, Sp.PA Anatomy Phatology 081338736481
7 dr. Ida Bagus Ngurah, M.For Pharmacology 08123687288
8 dr. Gde Kambayana, Sp.PD Interna 08124683416
9 Dr. dr. Elysanti, Sp.Rad Radiology 081805673099
10 dr. Putu Gede Sudira Sp.S Neurology 081805633997
11 dr. I G.N.A. Lanang Artha Wiguna Sp.OT(K) surgery 0811388859
12 dr. Wayan Subawa Sp.OT Surgery 081337096388
13 Prof.dr. Ketut Siki Kawiyana Sp.B,Sp.OT Surgery 0811392124
14 dr. K.G. Mulyadi Ridia, Sp.OT Surgery 08123972029
15 dr. Wayan Suryanto Dusak, Sp.OT Surgery 08123801878
16 Dr.dr.I Ketut Suyasa, Sp.B, Sp.OT(K) Surgery 0811392640
17 dr. I G.N. Wien Aryana, Sp.OT Surgery 0811385263
18 dr. I Gede Eka Wiratnaya, Sp.OT Surgery 081338493832
19 Prof.Dr. dr.Tjok Raka Putra, Sp.PD Interna 08123811354
20 dr. Cokorda Dalem Kurniawan, Sp.KFR Rehabilitasi Medis 08123800149
21 dr. M.Bramantya Karna, Sp.OT (K) Surgery 0817300133

~ FACILITATORS ~
Regular Class (Class A)
Venue
No Name Group Departement Phone
(3rd floor)
3rd floor:
1 dr. I.B. Ngurah, M.For, AIFO A1 Pharmacology 08123687288
R.3.09
3rd floor:
2 dr. I Gde Haryo Ganesha S.Ked A2 DME 081805391039 R.3.10
Dr. dr. Komang Januartha Putra 3rd floor:

3 A3 Microbiology 08123831710 R.3.11
Pinatih, M.Kes
dr. Ida Ayu Dewi Wiryanthini, 3rd floor:
4 A4 Biochemistry 081239990399 R.3.12
M.Biomed
3rd floor:
5 dr. Yukhi Kurniawan, Sp.And A5 Andrology 08123473593 R.3.13
3rd floor:
6 dr. I Kadek Swastika, M.Kes A6 Parasitology 08124649002 R.3.14
dr. dr. luh Putu Ratna Sundari, 3rd floor:

7 A7 Physiology 081933070077 R.3.15
M.Biomed
3rd floor:
8 dr. I Made Dwijaputra Ayusta, Sp.Rad A8 Radiology 08123670195 R.3.16
3rd floor:
9 dr. Putu Cintya Denny Yuliyatni, MPH A9 Public Health 081353380666
R.3.17
Clinical 3rd floor:
10 Dr.dr. I Nyoman Wande, Sp.PK A10 08124686885
Pathology R.3.19
Regular English (Class B)
Venue
No Name Group Departement Phone
(3rd floor)
3rd floor:
1 dr. Yuliana, M.Biomed B1 Anatomy 085792652363
R.3.09
3rd floor:
2 Dr. dr. Putu Asri Damayanti, M.Kes B2 Parasitology 082237396899 R.3.10
3rd floor:
3 dr. I.G.N. Sri Wiryawan, M.Repro B3 Histology 082341768888 R.3.11
dr. Ni Nengah Dwi Fatmawati, Sp.MK, 3rd floor:

4 B4 Microbiology 087862200814 R.3.12
Ph.D
Anatomy 3rd floor:
5 dr. I Wayan Juli Sumadi, Sp.PA B5 082237407778 R.3.13
Pathology
3rd floor:
6 dr. Agung Nova Mahendra, M.Sc B6 Pharmacology 087861030195 R.3.14
3rd floor:
7 dr. I Made Winarsa Ruma, S.Ked. PhD B7 Biochemistry 087785356853 R.3.15
3rd floor:
8 dr. I Putu Adiartha Griadhi, M.Fis B8 Physiology 081999636899 R.3.16
dr. Luh Oliva Saraswati Suastika, 3rd floor:
9 B9 Cardiology 081330530247
Sp.JP, FIHA R.3.17
Internal 3rd floor:
10 dr. I Ketut Suardamana, Sp.PD-KAI B10 08123985811
Medicine R.3.19

Lecture Schedule 2018

DAY / TIME
ACTIVITY VENUES CONVEYER
DATE Regular Class English Class
Lecture : 10.00 – 11.00

08.00 – 09.00
1. Appendicular Skeleton 11.00 – 12.00 Prof Mangku
09.00 – 10.00 Class room
2. Congenital Bone Disorder (CTEV,DDH,Scoliosis) Prof. Siki
1 10.00 – 11.30 09.00 – 10.00

Fascilitator
Individual learning 13.30 – 15.00
26/2 SGD
12.00 – 13.30 Discussion room
11.30 – 12.00 12.00 – 12.30

Break
Prof.Mangku/
Class room Prof. Siki
Self assessment 13.30 – 14.00 12.30 – 13.30
Plenary 14.00 – 15.00 15.00 – 16.00
Lecture :
Metabolism Disorders (Osteoporosis) and 08.00 – 09.30 09.30 – 11.00
Pathological Fracture
Class room Prof. Siki
Individual learning 09.30 – 10.30 11.00 – 12.00
2 SGD 10.30 – 12.00 12.00 – 13.30
27/2 Discussion room Fascilitator
Break 12.00 – 12.30 13.30 – 14.00
12.30 – 14.00 14.00 – 15.00

Self assessment & Student Project Class room Prof. Siki
Plenary 14.00 – 15.00 15.00 -16.00
Lecture :
Bone Development and It’s Microscopic
08.00 – 09.00 09.00 – 10.00 dr. Lina
Structure Class room
09.00 – 10.30 10.00 – 11.30 Facilitator
3 Individual learning
SGD
10.30 – 12.00 12.00 – 13.30
Discussion room
28/2 12.00 – 12.30 11.30 – 12.00

Break
Self Assessment and Student Project 12.30 – 14.00 13.30 – 15.00 Class room
14.00 – 15.00 15.00 – 16.00 dr. Lina
Plenary
Lecture :
Pathology Anatomy of Musculoskeletal 08.00 – 09.00 09.00 – 10.00 Class room
Diseases dr. Mahendra Dewi
SGD
09.00 – 10.30
10.30 – 12.00
10.00 – 11.30
12.00 – 13.30
Discussion room
Facilitator
1/3 12.00 – 12.30 11.30 – 12.00

Break
Self Assessment and Student Project dr. Mahendra Dewi

12.30 – 14.00 13.30 – 15.00 Class room
Plenary 14.00 – 15.00 15.00 – 16.00

5 Lecture :
Orthopaedic Problem And Its Management
08.00 – 09.00 09.00 – 10.00 Class room Dr. Elysanti, Prof.
Astawa
5/3 09.00 – 10.30 10.00 – 11.30 Discussion room Facilitator
10.30 – 12.00 12.00 – 13.30
Individual learning
SGD 12.00 – 12.30 11.30 – 12.00
Break
13.30 – 15.00 Class room Dr. Elysanti, Prof.
Self Assessment and Student Project 12.30 – 14.00 15.00 – 16.00 Astawa
Plenary 14.00 – 15.00
Lecture : 09.00 – 10.00

08.00 – 09.00 Class room
Anatomy Bone, Joint and Ligament Prof.Mangku
10.00 – 11.30
Individual learning 09.00 – 10.30
6 SGD 10.30 – 12.00
12.00 – 13.30 Discussion room
Facilitator
6/3 Break 12.00 – 12.30
11.30 – 12.00
Self Assessment and Student Project

13.30 – 15.00 Class room
Plenary 12.30 – 14.00
15.00 – 16.00
Prof. Mangku
14.00 – 15.00
Lecture :
Bone, Joint, Tendon, and Soft Tissue injury 08.00 – 09.00 09.00 – 10.00 Prof. Astawa/
Class room
(Upper Limb) dr.Bramantya
7 Individual learning 09.00 – 10.30 10.00 – 11.30
Discussion room
Facilitator
7/3 SGD 10.30 – 12.00 12.00 – 13.30
Break 12.00 – 12.30 11.30 – 12.00
Self Assessment and Student Project 12.30 – 14.00 13.30 – 15.00

Prof. Astawa/
Class room
Plenary 14.00 – 15.00 15.00 – 16.00 dr.Bramantya
Lecture :
Bone, Joint, Tendon, and Soft Tissue injury (
Lower Limb) 08.00 – 09.00 09.00 – 10.00
Class room Dr. Suyasa/
dr. Wien Aryana
SGD
09.00 – 10.30
10.30 – 12.00
10.00 – 11.30
12.00 – 13.30
8/3 12.00 – 12.30 11.30 – 12.00 Discussion room Facilitator
Break
Dr. Suyasa/
Self Assessment and Student Project 12.30 – 14.00 13.30 – 15.00
14.00 – 15.00 15.00 – 16.00
Class room dr. Wien Aryana
Plenary
Lecture :
09.00 – 10.00 dr. Arijana
Skeletal Muscles 08.00 – 09.00
Class room
Facilitator
09.00 – 10.30
10.00 – 11.30
12.00 – 13.30
Discussion room
9/3 SGD
10.30 – 12.00
11.30 – 12.00
Break 12.00 – 12.30
12.30 – 14.00
13.30 – 15.00 Class room dr. Arijana
Self Assessment and Student Project 15.00 – 16.00
Plenary 14.00 – 15.00
Lecture :
10 Muscle Contraction As a Trigger Of Movement
08.00 – 09.00 09.00 – 10.00
Class room
Prof. Adiatmika
12/3 Individual learning 09.00 – 10.30 10.00 – 11.30
SGD 10.30 – 12.00 12.00 – 13.30 Discussion room Facilitator

Break 12.00 – 12.30 11.30 – 12.00
Self Assessment and Student Project

12.30 – 14.00 13.30 – 15.00
Plenary 14.00 – 15.00 15.00 – 16.00
Class room Prof. Adiatmika
Lecture :
1. Neurologic Aspect in Musculoskeletal 08.00 – 09.00 10.00 – 11.00 dr. Sudira,
Disease 09.00 – 10.00 11.00 – 12.00 dr. Kambayana
Class room
2. RNA
10.00 – 11.30 09.00 – 10.00
Discussion room
Facilitator
13/3 SGD
11.30 – 12.00 12.00 – 12.30
Break dr. Sudira
Class room
13.30 – 14.00 12.30 – 13.30
Self Assessment 14.00 – 15.00 15.00 – 16.00 , dr. Kambayana
Plenary
Lecture :
1.Disorders of Spine (LBP, Spondylitis TB, 08.00 – 09.00 10.00 – 11.00
Fracture) 09.00 – 10.00 11.00 – 12.00 Class room dr. Mulyadi Ridia,
2. Musculoskeletal Rehabilitation dr Cok Dal
12 Individual learning 10.00 – 11.30
12.00 – 13.30
09.00 – 10.00
13.30 – 15.00
Discussion room Facilitator
14/3 SGD
Break 11.30 – 12.00 12.00 – 12.30

Class room dr. Mulyadi Ridia,
dr cok dalem
Self Assessment 13.30 – 14.00 12.30 – 13.30
Plenary 14.00 – 15.00 15.00 – 16.00
Anatomy Dept. (1st
fl)
13 Basic Clinical Skill 09.00 – 14.00 09.00 – 14.00
Histology Dept. (4th
fl) Team
15/3 Plenary 15.00 – 16.00 15.00 – 16.00 Physiology Dept.
(2nd fl)
Anatomy Dept. (1st

fl)
fl) Team
(2nd fl)
Anatomy Dept. (1st

fl)
15 Basic Clinical Skill 09.00 – 14.00 09.00 – 14.00 Histology Dept. (4th
Team
20/3 Plenary 15.00 – 16.00 15.00 – 16.00 fl)
Physiology Dept.
(2nd fl)
Anatomy Dept. (1st
fl)
fl) Team
(2nd fl)
Anatomy Dept. (1st

fl)
Basic Clinical Skill 09.00 – 14.00 fl)
17 Plenary
09.00 – 14.00
15.00 – 16.00
15.00 – 16.00 Physiology Dept. Team
23/3 (2nd fl)

08.00 – 09.00
Lecture : 10.00 – 11.00
09.00 – 10.00 Dr. Eka W
1.Neoplasm of Bone, joint and soft tissue 11.00 – 12.00 Class room
dr. Dusak
2. InfectionOf Bone, Joint and soft tisuue
10.00 – 11.30
09.00 – 10.00
18 Individual learning 12.00 – 13.30
13.30 – 15.00 Facilitator
SGD Discussion room
26/3 11.30 – 12.00
12.00 – 12.30
Break
13.30 – 14.00
12.30 – 13.30
Dr. Eka W
Self Assessment 14.00 – 15.00 Class room
15.00 – 16.00 dr. Dusak
Plenary
Lecture :
Bone And Immunology Disorder 08.00 – 09.00 09.00 – 10.00 Class room
(Osteoarthritis and Gout Arthtitis) Prof. Tjok Raka
SGD
09.00 – 10.30
10.30 – 12.00
10.00 – 11.30
12.00 – 13.30
Discussion room
Facilitator
27/3 12.00 – 12.30 11.30 – 12.00
Break
Class room
Self Assessment and Student Project Prof. Tjok Raka
12.30 – 14.00 13.30 – 15.00
Plenary 14.00 – 15.00 15.00 – 16.00
Lecture :
1.NSAID 08.00 – 09.00 10.00 – 11.00 Class room dr. Alit,
2. Medicolegal Aspect of Trauma 09.00 – 10.00 11.00 – 12.00 farmako
Musculoskeletal
Discussion room Facilitator
28/3 SGD 12.00 – 13.30 13.30 – 15.00
Break 11.30 – 12.00 12.00 – 12.30
Class room
Self Assessment 13.30 – 14.00 12.30 – 13.30 dr.Alit, Farmako
Plenary 14.00 – 15.00 15.00 – 16.00
ATTENTION :
PREEVALUATION BREAK : THURSDAY, 29 March 2018
EXAMINATION DAY : Monday, 2 April2018
Class Room : R. 3.02 (3rd Floor)

Schedule
Basic Clinical Skill
CLASS ROOM JOINT LAB

DAY
ANATOMY (PHYSICAL PHYSIOLOGY
/ PATHOLOGY HISTOLOGY
DEPT DIAGNOSTIC DEPT
DATE ANATOMY DEPT
MSD)
08.00 – 11.00 11.30 – 14.30
15 A B C D E
15/3
16 B C D E A
19/3
17 C D E A B
20/3
18 D E A B C
22/3
19 E A B C D
23/3
Group Distribution Member

Basic Clinical Skill
REGULAR CLASS ENGLISH CLASS

GROUP
(ABSENT NUMBER) (ABSENT NUMBER)
A 1 – 60
B 11 – 120
C 121 – 148 1 – 32
D 33 – 92
E 93 – 146
Total Student 148 146
ATTENTION :
EXAMINATION DAY : Monday, 2 April 2018

Class Room : R. 3.02 (3rd Floor)

Students Meeting Representatives

In the middle of block schedule, a meeting is designed among the student
representatives of every small group discussion, facilitators and resource persons. The
meeting will discuss the ongoing teaching learning process, quality of lecturers and
facilitators as a feedback to improve the next process. The meeting will be held based on
schedule from Medical Education Unit.
Student project and Individual Learing

For a more comprehensive achievement in studying the whole topics in this Block,
the student must spend the time alocation properly including Individual Learing. At this time,
the student must read the references and make synthesis from the references. The goal
is the student could fullfil the learning objectives of each topic and in accordance to SKDI.
As a proof of good individual learning process has been done properly, the student must
write the synthesis for each topic during the Individual Learning session and must be
showed and signed by the facilitator after SGD. Please completed the student project by
handwriting, not by computer.
Assessment
Type of assessment is multiple choice questions (MCQ) and fill the blank and OSCE.
A prerequisite condition to follow the assessment is attendance in at least 75% of all
scheduled teaching-learning activities and follows the questionnaire test during lecture.
Students’ assessment consists of summative assessment that is given at the end of lecture.
Main examination be held at 2 April 2018 and OSCE will be conducted together with other
block at semester IV.
The score main examination will be calculated from questionnaire during lecture (5
%), Student Project (10 %), MCQ (80 %) and SGD (5 %). Passing level is 65 or above. The
student who does not pass the passing level should follow remedial. For those student who
get score 64.5 – 64,9 must write paper about musculoskeletal in accordance to
musculoskeletal from SKDI. The student who get score below than or similar to 64.4 must
follow test. Remedial will be held later. Remedial topics are just for the fail topic or not pass.
So, the student must follow the topics that are not yet pass to substitute the main
examination. The best score will be used for final calculation.

LEARNING PROGRAM
Day 1st
MODULE
1
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 shoulder/buttock, fore arm/femur, lower arm/leg,
hand/pedis
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
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 shoulder/buttock, fore arm/femur, lower
arm/leg, hand/pedis

Day 1st
MODULE
2
CONGENITAL BONE DISORDER
Prof. Dr. dr, I Ketut Siki Kawiyana,SpB. SpOT(K)
AIMS:
Establish tentative diagnosis, provide initial management and/or refer patient with congenital
anomaly of musculoscletal system.
LEARNING OUTCOME:
Establish tentative diagnosis, provide initial management and/or refer patient with
o CTEV
o CDH
o SCOLIOSIS
CURRICULLUM CONTENTS:
1. Principle management of congenital anomaly of musculoscletal system.
2. Establish tentative diagnosis, provide initial management and/or refer patient with
a. CTEV
b. CDH
c. SCOLIOSIS
ABSTRACTS
CTEV (Congenital Talipes Equinovarus).

Synonym is a Clubfoot. It is a common birth defect, occurring in about one in every
1.000 live birth. Approximately 50% of case of clubfoot is bilateral. In most case it is an
isolated dysmelia. Incidence in males is slightly higher than females.
Cause: There is different cause for clubfoot. It is not known what the exact cause of
clubfoot may be, but it has be found common in individuals with Edwards syndrome, a
genetic defect, external influences such as intrauterine compression from oligohydramnion
or from amniotic band syndrome. CTEV may be associated with use of medicamentous
while pregnant.
Clinical sign: The foot is twisted in (inverted) and down. The deformities are Equinus
of the ankle, varus of hind foot, supination of midfoot, and adduction of forefoot. Without
treatment, person afflicted often appear to walk on their ankles, or on the sides of their feet.
Treatment: Clubfoot is treated by non operative or operative. By non operative,
clubfoot is treated with manipulation and is followed by serial casting, most often by the
Ponseti Method. Foot manipulation is usully done as soon as possible or within two weeks
of birth. Even with successful treatment, when only one side is affected. Surgery is indicated
in rigid or neglected clubfoot. In the chilled under 5 years old, posteromedial soft tissue
release must be done, there are ATL, lengthening of tibialis posterior tendon, flexor
digitorum and flexor hallucis tendon, and release, and release all of ligament and joint

capsule on the medial foot and ankle. In chilled over then 10 years old, bone procedure
must be done.
DDH (Developmental Dysplasia of Hip)

Developmental Dysplasia of Hip is congenital (present at birth) condition of the hip
joint. It occurs once in every 1.000 live birth. The hip joint is created as a ball and socket
joint. In DDH, the hip socket may be shallow, letting the “ball” also known as the femoral
head, slip in and out of the socket. The femoral head may move partially or completely out
of the hip socket.
Cause: The greatest incidence of DDH occurs in first-born females. Hip dysplasia is
considered a “multifactorial trait”. Multifactorial inheritance means that many factors are
inveloved in causing a birth defect. The factors are usually both genetic and environmental.
The risk factors for DDH are:
- Family history of developmental dysplasia of the hip, or very flexible ligament.
- Position of the baby in the uterus, especially with breech presentations.
- Associations with other orthopaedic problems that include metatarsus adductus,
clubfoot, and arthrogryposis multiplex congenital.
Diagnosed of DDH: The symptoms and sign may include:
- The leg may appear shorter.
- The leg turns outward.
- The folds in the skin of tight or buttocks may appear uneven.
- The space between the legs may look wider than normal.
Diagnostic procedure may include:
- X-ray of the pelvis.
- Ultra sound (Sonography).
- CT scan (Computed tomography scan).
- MRI (Magnetic resonance imaging).
Treatment for DDH: The goal of treatment is to put the femoral head back into the socket of
the hip, so that the hip can develop normally.
Treatment options vary for babies and may include:
- Placement of a Pavlik harness.
- Traction and casting.
- Surgery and casting.
SCOLIOSIS
Scoliosis in 3-demensional spine deformity and The Scoliosis Research Society defines
scoliosis as a curvature of the spine measuring 10 degrees or greater. In over 80 percent
of cases, the cause of scoliosis is unknown ,a condition called idiopathic scoliosis. Scoliosis
is more common in females than males. 3 different types of scoliosis that can occur in
children : Congenital (present at birth), Neuromuscular, or Idiopathic. Diagnose of scoliosis
based on complete medical history and physical examination, and X-rays (Scoliosis
program). In establishing a diagnosis of scoliosis, the physician measures the degree of
spinal curvature on the X-ray using Cobb Angle. The goal of treatment is to stop the
progression of the curve and prevent deformity. Treatment:Observation and repeated
examinations, Bracing And Surgery. The management of scoliosis is individualized for each
child depending on his or her age, amount of curvature, and amount of time remaining for
skeletal growth. Scoliosis will require frequent examinations by your child's physician to
monitor the curve as your child grows and develops. Early detection is important. If left
untreated, scoliosis can cause problems with heart and lung function.

1. Concept of congenital abnormalities

2. Type of congenilat abnormalities

3. Management patient with congenital abnormalities
SCENARIO
Case I
A lecturer showed one of his medical students, a 4 months old female patient with
abnormalities in her left lower limb, shortening in her thigh, adducted and difference in skin
fold between her right and left thighs. Lecturers said this patient might be having DDH
(Developmental Dysplasia of the Hip)
1. Where is the abnormality occured and why is it called DDH?
2. What are the incidence, etiology and pathogenesis of DDH?
3. How do you diagnosed and treat DDH patient based on age of the patient?
Case II
A normal male baby was born in a maternity clinic, with normal body weight, cried
spontaneous after examined by midwife. She found both of the baby’s legs bowed inwards.
She has a daughter studying in medical faculty. She asked her daughter about the
abnormalities in this baby and how to treat this baby appropriately.
1. What are the congenital abnormalities found in lower limb?
2. What are the causes of bowed legs?
3. In this case, what are the deformities found in leg and ankle?
4. How do you manage this baby and when do you start the treatment?
Case III
Maother complaint her 2 years old boy with both bow leg and getiing worst since 6 month
ago. Her son look obese and with difficulty in walking.
1. What are the congenital abnormalities found in this child and the differential diagnosis?
2. What are the radiologic examinations needed to be done for this patient?
3. What are the radiologic imaging are expected in this patient?
4. How doyou manage this boy ?
Learning Task:
1. Definition of congenital abnormalities in musculoskeletal system
2. Congenital abnormalities that is common found
3. Signs and diagnostic criteria
4. Management procedures
5. Consultation patient with congenital abnormalities
Self Assessment:
1. What is the meaning of congenital abnormalities?
2. When do you refer a newborn baby with congenital abnormalities?
3. Genu Valgum and Genu Varum (blount’s disease)?
4. Pes Planus , Calcaneovalgus, Pes Cavus?
5. Radial Club Hand ?
6. Scoliosis?
7. Achondroplasia?

Day 2nd
MODULE
3
BONE AND METABOLISM DISORDERS
Prof. Dr. dr. I Ketut Siki Kawiyana, SpB. SpOT (K)
AIMS:
methabolic disorders.
LEARNING OUTCOMES:
Establish tentative diagnosis, provide initial management and/or refer patient with :
osteoporosis, rickets osteomalacea.
1. Osteoporosis
2. Rickets
3. Osteomalacea.
ABSTRACTS
OSTEOPOROSIS
Osteoporosis is a disease that thins and weakens the bones to the point that they
become fragile and break easily. Women or men with osteoporosis most often break bones
in the hip, spine, and wrist, but any bone can be affected.
Osteoporosis is often called “silent” because bone loss occurs without symptoms. People
may not know that they have osteoporosis until a sudden strain, bump, or fall causes a bone
to break. Bone is living tissue. Throughout our live, the body breaks down old bone and
replaces it with new bone (remodeling). But as people age, more bone is broken down than
is replaced. The bone will become thin and porous (osteoporosis).
Risk Factor:
- Gender.
- Age.
- Ethnicity.
- Family history.
- Life style: diet, Calcium, vit D,
- Physical activity.
- Smoking
- Low body weight
- Medication

Sign and Diagnosis:

Osteoporosis does not have any symptoms until a fracture occurs, most often break
bones in the hip, spine, and wrist. If spine fractures, height loss, back pain, back fatigue,
curved spine.
The best screening test is dual energy X-ray absorptiometry (DEXA). This procedure
is quick, simple and gives accurate results. It measures the density of bone in spine, hip and
wrist.
Treatment & drugs:
Prescription drugs can help slow bone loss and may even increase bone density
over time. It was including: hormonal therapy, bisphosphonates, and calcitonin.
Prevention:
Getting adequate calcium and vitamine D is an important factor in reducing risk of
osteoporosis. Other tips for prevention: exercise, add soy to diet, don’t smoke, avoid
excessive alcohol, and limit caffeine.

1. Clinical aspect of Osteoporosis
2. Differential diagnosis of osteoporosis
3. Management of osteoporosis.
SCENARIO
A 60 year old woman came to the orthopaedic clinic due to pain on her back since a
year ago and already got treatment from general practitioner. She said that her back start to
bent since 3 months and severe pain since yesterday because of fall down in sit position.
She had gynecological operation when she was 40 year old
1. Please make imaginative anamnesis in this patient to lead to osteoporosis
diagnosis.
2. What is the Differential Diagnosis? Please explain other examinations which can
distinguish the DD.
3. What is the definition of osteoporosis?
4. What is the pathogenesis?
5. Is osteoporosis happened in female only?
6. How to prevent it?
7. In which bone, can fracture happened if this patient fell down?
Learning Task:
1. Osteoclast and osteoblast function
2. Bone remodeling process
3. Factors that affect bone remodeling
Self Assessment:
1. What is the osteoporosis classification?
2. Why in colles fracture often associate with pathological fracture?

Day 3rd
MODULE
4
BONE DEVELOPMENT AND ITS MICROSCOPIS STRUCTURE
Dr.dr. Ni Made Linawati, M.Si
MICROSCOPICS OF BONE
AIMS :
1. Describe normal bones as structure and bone as an organ and apply its concepts
and principles in the approach of patient with healing/injury
2. Describe several factors that affect to regulation of calcium and bone remodeling in
the patient with healing/injury
LEARNING OUTCOME:
1. Comprehend the concept of microscopic bone structure and it’s development
2. Apply the concept to clinical case such as osteoporosis, bone fracture
3. Comprehend the physiology of calcium and its regulation within the body.
4. Apply the concept calcium balance to bone fracture / injury
a. Bone :
 Intra membraneous ossification
 Endochondral Ossification
 Compact / lamellar bone
 Woven bone
b. Cartilage :
 Hyaline cartilage
 Elastic cartilage
 Fibrocartilage
c. Bone development
d. Bone deposition, bone absorption
ABSTRACTS
Cartilage and Bones

Cartilage is characterized by an extracellular matrix enriched with
glycosaminoglycans and proteoglicans, macromolecules that interact with collagen and
elastic fibers. Variations in the compositione matrix component produce 3 types of cartilage
adapted to local biomechanical needs. Cartilage consists of cells called chondrocytes and
an extensive extracellular matrix composed of fibers and ground substance. Condracytes
synthesize and secrete the extracellular matrix and the cells themselves are located in

matrix cavities called lacunae. There are three forms of cartilage: hyaline cartilage, elastic
cartilage and fibrocartilage.
Bone is specialized connective tissue composed of intercellular calcified material, the bone
matrix, and 3 cell types: osteocytes, osteoblasts and osteoclast. Microscopic
examination of bone shows 2 varieties: primary, immature or woven and secondary,
mature or lamellar bone. Bone can be formed in 2 ways: by direct mineralization of matrix
secreted by osteoblast (intramembranous ossification) orby deposition of matrix on a pre-
existing cartilage matrix (endochondral ossification).
Jointregions were bones that are capped and surrounded by connective tissue that hold the
bones together and determine the type and degree of movement between them. Joint may
be classified as synostosis, synchondrosis and syndesmosis. In synostosis, bone is united
by bone tissue and no movement takes place. In children and young adult, are united by
dense connective tissue. Synchondroses are articulations in which the bone is joined by
hyaline cartilage. Diarthroses are joints that generally unite long bones and have great
mobility. In this joint, ligament and a capsule of connective tissue maintain the contact at the
end of bone. The articular surfaces of a diarthrosis are covered by hyaline cartilage that is
devoid of perichondrium. The capsule of dioarthroses varies in structure according to the
joint. Generally, this capsule is composed of 2 layers, the external fibrous layer and the
internal synovial layer. The synovial layer is formed by two types of cells. One resembles
fibroblast and the other has the aspect and behavior of macrophages. The fibrous layer is
made of dense connective tissue.
Bone growth and remodeling

Bone growth was affected by several factors such genetics, nutrition, endocrine dan
nerve. Bone tissue development consists of primary and secondary process. Osteogenesis
is the process of bone growth until 18 years old for female and 21 years old for male.
Osteoblasts will secret osteoid, as one kind of collagen fibers which not yet reach for the
classification process. Calcificaton process occurred about 1 week.
Active substance of vitamin D (1,25-dyhidroxycholecalciferal) was arranged through
skin where the 7-dehydrocholesterol was changed to vitamin D3. The vitamin D3 will be
changed to be 25-hydroxycholecalciferol within the liver. The 25-hydroxycholecalciferol will
be changed to be 1,25-dyhydroxycholecalciferal within the renal cortex. This process
supported by parathyroid hormone. Meanwhile, calcium absorption was occurred in the
intestine and affected by 1,25 dyhydroxycholecalciferol within intestine epithelial.
Bone remodeling was affected by (1) mechanical stress that stimulates the bone
harder at the stress point. ; (2) Parathyroid hormone and 1,25-dyhydroxycholecalciferol that
stimulates osteoclast activity; and (3) calcitonin that decreasing osteoclast absorption
capacity and reducing new osteoclast development. Bone remodeling was a dynamic
process for long life and a balance process of osteoblast dan osteoclast function.

1. Microscopic view of bone cell
2. Composition of bone cell
3. Bone development
4. Calcium balance
5. Bone remodeling
SCENARIO
Female 13 years old, had first menstrual cycle. She complained about her height
that couldn’t increase again.
Learning Task :
1. Describe the histogenesis of cartilage

2. Describe the normal structure and function of hyaline, elastic and fibrocartilage
3. Describe the microscopic structure of osteoprogenitor cells, osteoblast, osteocyte,
osteoclast and bone matrix
4. Describe the organization of immature and lamellar bones
5. Describe the histogenesis of bones, included :
a. Intramembraneous and endochondral ossification
b. Growth in length of long bones
c. Growth in diameter of long bones
d. Surface modeling of bones
6. Describe the histology structure of articular surface of joint.
Self Assesment
1. Chondrogenesis (cartilage growth) takes place by two mechanisms: (1)……….. and
(2)………………..
2. The two major cell components of bone are the …………….. and…………………
3. Explain the process of bone growth and remodeling
SCENARIO
A woman, 45 years old, come to hospital for thyroid and parathyroid surgery. For the
preparation, the patient must do some assessment and therapy a better result after surgery.
Learning Task :
1. Identify any assessment that must done by this patient.
2. Explain what the effect of parathyroid surgery to the other organ and calcium
balance.
Self Assesment
1. What is the effect of parathyroid surgery ?
2. What should be given to patient to avoid hypocalcemia ?
3. What is the mechanism of organ to anticipate loss of parathyroid organ after the
surgery ?
Reference:
1. Junquera LC. 2003. Cartilage and Bone in Basic Histology tenth edition. P. 135-156
2. Textbook of Medical Physiology, 10th ed, A.C. Guyton, Hall, Philadelphia, WB
Saunders Co, 2000, pp. 52 – 95

Day 4th
MODULE
5
PATHOLOGY ANATOMY OF MUSCULOSKELETAL DS
Dr. dr. I G.A.Sri Mahendra Dewi, SpPA
AIM:
Describe the etiopathogenesis and morphologic features of musculoskeletal
diseases and apply it concept for approach of musculoskeletal problems and its therapy.
LEARNING OUTCOMES :
1. Bone
1.1 describe the effect (etiopathogenesis and morphologic features) of stress/ injury/
disease to bone.
2. Joint
2.1 describe the effect (etiopathogenesis and morphologic features) of stress/ injury/
disease to joint.
3. Muscle
3.1 describe the morphologic features of skeletal muscle tumors.
3.2 describe the morphologic features of smooth muscle tumors.
4. Soft tissue
4.1 describe the morphologic features of adipose tissue tumors.
4.2 describe the morphologic features of fibrous tissue tumors.
CURRICULUM CONTENTS
1. Bone
1.1 Congenital and Hereditary Diseases of Bone : Achondroplasia, Osteogenesis
Imperfecta
1.2 Osteoporosis and Acquired Metabolic Diseases (Rickets and Osteomalacia)
1.3 Osteomyelitis and Spondilitis
1.4 Bone Tumors : primary and secondary bone tumors, osteosarcoma, Ewing sarcoma,
fibrous dysplasia
2. Joint : arthritis (gout arthritis and infectious arthritis), osteoarthritis,

3. Muscle : rhabdomyosarcoma, leiomyoma, leiomyosarcoma
4.Soft tissue : adipose tissue tumors (lipoma, liposarcoma), fibrous tissue
tumors (fibroma, fibrosarcoma)
ABSTRACT
1. BONE
Achondroplasia is an inherited disorder characterized by impaired maturationof
cartilage in the developing growth plate. The most conspicuous changes are marked,
disproportionate shortening of the proximal extremities, bowing of the legs, and a lordotic
(sway-backed) posture. The cartilaginous growth plates contain hypoplastic or disorganized
aggregates of chondrocytes instead of the long, orderly columns normally seen at this site.
Osteogenesis Imperfecta (OI) or brittle bone disease, is a group of hereditary
conditions characterized by abnormal development of type I collagen. Type I collagen is

present in many different tissues, including skin, joints and eyes. OI characterized by the
present of multiple bone fractures. Other tissues containing type I collagen are also
affected, resulting in abnormal dentition, hearing loss, and blue appearance to the sclera.
Osteoporosis is a skeletal disorder characterized by low bone mass and
microarchitectural deterioration with a subsequent increase in bone fragility and
susceptibility to fracture. It occurs most commonly as primary disorders or secondary.
Osteoporosis result when imbalance occurs between bone formation and resorption. The
hallmark of osteoporosis is a loss of bone, the bony trabeculae are thinning and widening of
haversian canal.
Both rickets and osteomalacia are manifestations of vitamin D deficiency. The
fundamental change in these diseases is defective mineralization of bone, accompanied by
an increase in nonmineralized osteoid. In rickets, the defective mineralization involves the
developing bones in children, but osteomalacia involves the bone that has completed its
normal development.
Osteomyelitis designated as inflammation of the bone and marrow cavity by infectious
agents. Osteomyelitis may be an acute or chronic. The most common etiologic agents are
pyogenic bacteria and mycobacterium tuberculosis. Morphologically acute pyogenic
osteomyelitis characterized by an intense, neutrophilic inflammatory infiltrate. Chronic
osteomyelitis show sequestrum, involucrum and Brodie abscess. Tuberculous osteomyelitis
causes the granulomatous inflammatory reaction.
Bone tumors divided in two categories : bone-forming tumors (osteoma, osteoid
osteoma and osteoblastoma, and osteosarcoma) and cartilaginous tumors
(osteochondroma, chondroma, and chondrosarcoma).
- Osteosarcoma is malignant mesenchymal neoplasm in which the neoplastic cells
produce osteoid. Most unknown etiology. The lesion usually in the mataphyseal region
of the bone, often elevates the periosteum toproduce the Codman triangle on
radiographs. The hallmark of osteosarcoma is the formation of osteoid by malignant
mesenchymal cells, that may be spindle shaped, pleomorphic, bizarre, and giant cell
often present.
- Osteochondroma is benign proliferations composed of mature bone and a
cartilaginous cap. Probably represent malformations rather than true neoplasm.
- Chondrosarcoma is malignant neoplasm populated by mesenchymal cells that
produce a cartilaginous matrix. Microscopically, chondrosarcoma vary great in
appearance. There are well, moderately or poorly differentiated malignant cells,
multinucleate cells are present with lacunae containing 2 or more chondrocytes.
- Ewing sarcoma occurs predominantly in children and adolescents, with a peak
incidence in the second decade of life. Ewing sarcoma arises within the medullary
cavity of the affected bone to produce a soft, expansile mass. Microscopically it
composed of sheets of primitive cells, with small, fairly uniform nuclei and only scant
cytoplasm.
- Fibrous dysplasia is an uncommon, benign, tumor-like lesion of bone, in which the
normal trabecular bone is replaced by proliferating fibrous tissue and disorderly
islands of malformed bone.
2. JOINT
Osteoarthritis also termed degenerative joint disease. In most cases it arises without
obvious predisposing factors (primary). Morphologically, the earliest structural changes are
enlargement & disorganization of the chondrocytes in the superficial part of the articular
cartilage. These accompanied by fibrillation (splitting) at the articular surface. Portions of the
articular cartilage are eventually completely eroded, cyst may form in the underlying bone.
Additional bone proliferation occurs at the margins of the joints to produce bony
excrescences, termed osteophytes. Non specific inflammation can develops.
Gout is a disorder caused by the tissue accumulation of excessive amounts of uric
acid, an end product of purine metabolism. The major morphologic manifestation of gout are
acute arthritis, chronic tophaceous arthritis and soft tissue tophi, and gouty nephropathy.

The most common form of infectious arthritis is caused by bacteria. The usual reaction
manifested by local pain, fever and an intense neutrophilic inflammatory infiltrate within the
joint and periarticular tissues.
3. MUSCLE
Rhabdomyosarcoma is predominantly a neoplasm of infancy, childhood and
adolescence, with the peak incidence in the first decade of life. Microscopically there are
three variants : embryonal, alveolar and pleomorphic.
Leiomyoma is common benign smooth muscle tumors, encountered most frequently in
the uterus, composed of hyperplasia of smooth muscle cells arrayed in whorled-like without
anaplastic appearance.
Leiomyosarcoma is malignant smooth muscle tumors, occur most often in the uterus
and gastrointestinal tracts, composed of hyperplasia of smooth muscle cells with anaplastic
appearance, with infiltrative growth.
4. SOFT TISSUE
Soft tissue tumors are generally classified on the basis of tissue type that they
recapitulate, including tumors of adipose tissue (lipoma and liposarcoma), tumors of fibrous
tissue (fibroma and fibrosarcoma). Lipoma is benign tumor, soft, yellow mass, composed of
mature adipose tissue. Liposarcoma is malignant neoplasm, a number of different histologic
subtypes are recognized, including well-differentiated, myxoid, round cell, pleomorphic and
dedifferentiated liposarcoma. Fibrosarcoma is malignant neoplasm, composed of interlacing
fascicles of fibroblast, sometimes arranged in a ‘herringbone’ pattern.
SCENARIO
A 72 years old woman came to a general hospital with chief complain pain and
swelling in proximal region of her right lower extremity, after she fall in the bathroom.
Radiograph examination showed fracture of femoral neck and decreased of bone density.
Learning task :
1.1 What is the possible diagnosis of this patient ?
1.2 What are the role of hormonal factors in this case ?
1.3 Describe the morphologic features of the femoral bone of this patient.
A 22 years old man came to a doctor with chief complain swelling and pain in his
knee, enlarge fast since a week ago. Radiograph examination showed lesion in
metaphyseal region of distal femur, destroy the cortex, elevate periosteum and extend into
the soft tissue. Biopsy was done in this patient.
Learning task :
2.1.What is the possible diagnosis of this patient ?
2.2 Describe the morphologic features of the biopsy specimen.
A 35 years old man came to a general hospital with chief complain subcutaneous
masses, enlarge slowly since about 3 years ago, without pain. Biopsy was done in this
patient. The result of histopathological examination was lipoma.
Learning task :
3.1 Describe the morphologic features (macroscopic and microscopic) of the biopsy
specimen from this patient.
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,
andosteosarcoma).
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, 7th ed, Kumar V, Cotran RS, Robbins SL. WB Saunders,
Philadelphia, 2003, pp 755-787.

Day 5th
MODULE
6
ORTHOPAEDIC PROBLEM AND ITS MANAGEMENT
Dr. dr. Elysanti, SpRad
Prof. Dr. dr. Putu Astawa, SpOT(K), 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, SpOT(K). 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.

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.

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

Day 6th
MODULE
7
ANATOMY 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
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 axis/C2), (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)


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.

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
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:

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.

Day 7th
MODULE
8
BONE , JOINT AND SOFT TISSUE INJURIES
(UPPER LIMB)
DR. Dr. I Putu AstawaSpOT (K) M.Kes
dr.I Made Bramantya Karna SpOT (K)
AIMS:
Establish tentative diagnosis, provide initial management and/or refer patient with:
Fracture , dislocation and soft tissue injuries in child and adult of upper limb
LEARNING OUTCOMES:
Fracture, dislocation and soft tissue injuries in child and adult of upper limb
SHOULDER DISLOCATION
HUMERAL FRACTURE
SUPRACONDYLAR HUMERAL FR
MONTEGIA FR
GALLEAZI FR
SMITH FR
COLLES FR
MALLET FINGER
1. Tendon healing
2. Bone healing
3. Diagnosis, provide initial management and/or refer patient with: Fracture, dislocation
and soft tissue injuries in child and adult of upper limb.
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.
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.

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
3. The specific methods of treatment of closed fracture
4. The complication of fractures and complication of fracture treatment
5. Explain about 3 degree of joint instability
Self Assessment
a. Describe the special features of fractures and dislocation in children
b. Explain the specific methods of treatment of closed fracture
c. Describe about the complication of fractures
d. Describe about the complication of fracture treatment
SCENARIO
Male, 28 years old, came to emergency unit with painfull on the right elbow and
difficulty to movement his elbow after playing tennis. On physical examination;
tendernesson lateral side of right elbow.
Learning Task
1. Describe about Overuse injuries on the elbow
2. Describe sbout flexor and extensor tendon injuries of the hand
3. Explain achulles tendon injury
Self Assessment
a. Describe hand tendon injuries
b. Explain overuse injuries of the upperlimb and lowerlimb
c. Describe about meniscus injuries
d. Describe about Ganglion cyst
SCENARIO
A 40 year old woman comes to the emergency department because she has pain in
the right
arm two hours after she fell in her home. Physical examination shows swelling and
deformity of the right arm. The patient is unable to dorsiflex the wrist. X
ray studies show a spiral midshaft fracture of the humerus.
1. WHAT IS YOUR DIAGNOSIS?

2. WHAT NERVE WAS INJURED IN THAT FRACTURE?
Learning Task
1. Describe about ANATYOMY OF UPPER LIMB.
2. Describe ABOUT FUNCTION OF ULNAR, RADIAL AND MEDIAN NERVE

Self Assessment
a. Describe Healing of nerve injuries
b. Describe healing of tendon

Day 8th
MODULE
9
BONE , JOINT AND SOFT TISSUE INJURIES
(LOWER LIMB)
DR. Dr. I Ketut Suyasa SpB SpOT(K)
dr. IGN. Wien Aryana SpOT (K)
AIMS:
Fracture , dislocation and soft tissue injuries in child and adult of lower limb
LEARNING OUTCOMES:
Fracture , dislocation and soft tissue injuries in child and adult of lower limb
HIP DISLOCATION
FEMORAL FRACTURE
SUPRACONDYLAR FR OF FEMUR
KNEE INSTABILITY
LOWER LEG FRACTURE
FRACTURE ANKLE
Diagnosis, provide initial management and/or refer patient with: Fracture, dislocation
and soft tissue injuries in child and adult OF LOWER LIMB
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.


1. The type of fracture and healing process
2. THE DIFFERENT OF Fracture in adult and children
3. Management of fracture AND DISLOCATION
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 motorcyclist 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
SCENARIO
Male 25 years old, came to our hospital with painfull on he left hip and difficulty to
move his hip after traffic accident. He was motor cyclist and hit by a car.
On physical examination: Hip flexion, adduction and internal rotation
3. What is the complication ?
Learning Task
1. The special features of fractures and dislocation in adult and children
2. The general principles of fracture and dislocation treatment
3. How to diagnosis of fracture and associated injuries
Self Assessment
a. Describe the special features of fractures and dislocation in adult
b. Explain the general principles of fracture treatment
c. How to diagnosis of fracture and associated injuries
d. Describe 3 degree of joint instability
Decribe of joint trauma, hip, knee and ankle

Day 9th
MODULE
10
SKELETAL MUSCLES
dr. I.G Kamasan Nym Arijana, M.Si. Med
AIMS:
Describe normal of microscopic structure and function of skeletal muscles.
LEARNING OUTCOMES:
disorders such as degenerative disease of muscle (Duchene, Becker)
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 ).
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.

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?

Day 10th
MODULE
11
MUSCLE CONTRACTION AS MOVEMENT TRIGGER
Prof. Dr.dr. I Putu Gede Adiatmika, M.Kes
AIMS:
Describe bioelectric of excitation and muscle contraction.
LEARNING OUTCOMES:
disorders
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.

1. Action potential and its components
2. Process of muscle contraction
3. Transfer impus from neuron to cell

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
8. Describe the excitation contraction process from nerve to muscles

Day 11th
MODULE
12
Neurologic Aspect in Musculoskeletal Disease
dr. Putu Gede Sudira, SpS
(Will be delivered later – on scheduled)
RHEMATIC NON ARTHRICULAR (dr. Kambayana, Sp.PD)
(Will be delivered later – on scheduled)

Day 12th
MODULE
13
DISORDERS OF SPINE
dr. K.G. Mulyadi Ridia, SpOT (K)
LEARNING OBJECTIVE
Degenerativedisorders of spine.
CURICULIM CONTENT
1. Low Back Pain (LBP)
2. Neck Pain
ABSTRACTS (Dr. K.G. Mulyadi Ridia, SpOT (K))
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.

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. What are the structures in the lumbal area that might cause back pain?
2. What are the structures in the lumbal area that might cause neck pain?
3. What are the cause of back pain ?
SCENARIO
35 year old male, complained can not move his both leg after fell down from 3 meter
height. Physical Examination : Sensation: Hipoestesia below inguinal region, Motoric :
muscle testing lower limb 0
Learning Task:
Self Assessment:
1. Describe about Fracture and Dislocation of Spine?
2. Describe about Spondylolisthesis?
3. Describe about spondylosis?
Self Assessment
1. Describe about Spondylitis ?
2. Describe about Spine deformity: Scoliosis, Kyphosis & Lordosis?

Day 12th
MODULE
14
MUSCULOSKELETAL REHABILITATION
dr. Tjok Dalem Kurniawan, SpRM
AIMS:
Describe the Rehabilitation of musculoskeletal
LEARNING OUTCOMES:
Describe the Rehabilitation of musculoskeletal after injury degenerative disorders
a. Execerise Therapy
b. Deconditioning
c. Physical modality
d. Prosthesis
ABSTRACTS
Musculoskeletal disorders are the most frequent type of disabilities, and pain is the
most common cause musculoskeletal disability. Musculoskeletal complaint include non
specific symptoms such as pain in the neck, back, and extremities, chronic inflammatory or
degenerative disorders, and a wide range of sports injuries, traffic and occupation accident.
These disorder cause disability, suffering and reduce a person quality of life. Early
mobilization in musculoskeletal disorder is needed for preventing immobilization syndrome.
Management of rehabilitation for musculoskeletal disorders consist of giving some medicine,
physical modality, exercise therapy and sometime need walking aid

1. Rehabilitation for musculosceletal disorders
SCENARIO
Old men, 40 year, have a traffic accident. In emergency room, is got right thighbone
fracture and left forearm, then planned to do operation. After operation, right thigh muscle
minimizes and stiff in the knee and patient cannot walk.
Learning Task
1. Mention kind of exercise therapy
2. Mention complication of long immobilization!
3. Explain the way of prevention of that complication long immobilization!
4. Mention what physical modalities able to be used!
5. Mention kind of walking aid!

Self Assessment:
What is the role of rehabilitation for the musculoskeletal disorders treatment?

Day 13th - 17th

CLINICAL SKILL
MODULE
15
ANATOMY OF MUSCULOSKELETAL DS
Team
AIMS:
LEARNING OUTCOMES:
PROCEDURAL OF CLINICAL SKILL:
MODULE
16
HISTOLOGY OF BONE, CARTILAGE, MUSCLE
Team
AIMS:
To increase understanding about bone, cartilage and muscle

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 :
- 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 1/2
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 13th 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.
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:

MODULE
19
PHYSICAL DIAGNOSTICS OF MUSCULOSKELETAL DS
Team
AIMS:
LEARNING OUTCOMES:

Day 18th
MODULE
20
SOFT TISSUE & BONENEOPLASM
DR.Dr. Eka Wiryanata, Sp.OT
AIMS:
various soft tissues tumors and tumor-like lesion and benign neoplasm
LEARNING OUTCOMES:
various soft tissues tumors and tumor-like lesion and benign neoplasm
1. soft tissues tumors and tumor-like lesion and
2. Benign neoplasm
a. Osteochondrome
b. Gct
c. Osteoma
d. Osteoid osteoma
ABSTRACT
Bone tumor or tumor from bone is rare case that only 0.2 % from all tumors. Bone
tumors are benign and malignant. Cancers of bone can be primarily from bone itself, or
secunderly from another site.
Benign neoplasm of bone usually found unpredictable, because no specific symtoms
before it give complication like compression to the surrounding tissues or a fracture.
Conversely bone cancers always give similar signs as another diseases like osteomyelitis
or fracture of bone, and bone cancers always be found with bad condition.
The management of bone tumors particularly for malignant tumors, early diagnosis is
very imfortant for further treatment. The modality of management is defending on the
gradation. To know about the stadium, cooperation between orthopaedi, radiology and
pathology anatomy are necessary.
Vigilance for the bone tumors should be increase because sign of malignant bone
tumor always mistakable with another case. Malignant bone tumor usually (75%) attack
childrents and need radical surgery, extensive, and chemotherapy which uncomfortable,
and that are challenge to be an orthopaedic for treating bone tumors. Because of that to be
general practitioner to impeach bone tumor will increase early diagnosis and good result in
the management.

1. Diagnosis od soft tissue tumor
2. Management of soft toissue tumor
SCENARIO

Case 1
A boy come with lump at the bone of the right thigh close with knee, and below of the left
knee. His family doesn’t suffering disease like him, but his farent has lump like him.
Learning Task:
1. What the problem with him?
2. What kind of anamnesis which necessary for the patient?
3. What kind of physical examination and pem. Tambahan which necessary for the
patient?
4. If the the lump is benign, can you make the classification of bone tumor by Aegerter?
5. Explain, what the meaning with reactive bone lesion, hamartoma ?
6. What are the clinical feature, radiologic, and histopathology of the benign bone
tumors (Osteoma, Osteochondroma, GCT)
7. How the principely of the management of benign bone tumors?
Case 2
Seventeen year old boy, two weeks ago his right knee hited a table, and now his knee
swollen, redness, warm, and painfull.
Learning Task:
1. What x-ray should be performed?
2. What are yourdifferential diagnoses regarding on location where the patient
complaint?
3. May the patient suffer of malignant bone tumor?
4. What are the radiologically if true malignant bone tumor?
5. What is the prognosis base on the radiology imaging?
6. Can you explain the tumors which have radiology feature patognomonic?
Self Assessment:
1. Learn about the definition of benign and malignant bone tumors
2. Learn the classification of bone tumors
3. Learn about the relation between the location and kind of bone tumors?
4. Learn about the management of benign bone tumors
5. What the classification of bone tumor by Aegerter?
6. Can be the GCT classify into malignant bone tumor?
7. What kind of radiology appearance for the bone tumor generally?
NEOPLASM OF SOFT TISSUE & BONE (MALIGN)

AIMS :
Establish tentative diagnosis, provide initial management and/or refer patient with malign
neoplasm of the bone & soft tissue
LEARNING OUTCOME:
malign neoplasm of the bone soft tissue
Malign neoplasm of the bone soft tissue
1. osteosarcoma
2. chondrosarcoma

3. ewing tumor
ABSTRACTS
Bone tumor or tumor from bone is rare case that only 0.2 % from all tumors. Bone
tumors are benign and malignant. Cancers of bone can be primarily from bone itself, or
secunderly from another site (metastasis).
Benign neoplasm of bone usually found unpredictable, because no specific symtoms
before it give complication like compression to the surrounding tissues or a fracture.
Conversely bone cancers always give similar signs as another diseases like osteomyelitis
or fracture of bone, and bone cancers always be found with bad condition.
The management of bone tumors particularly for malignant tumors, early diagnosis is
very imfortant for further treatment. The modality of management is defending on the
gradation. To know about the stadium, cooperation between orthopaedi, radiology and
pathology anatomy are necessary.
Vigilance for the bone tumors should be increase because sign of malignant bone
tumor always mistakable with another case. Malignant bone tumor usually (75%) attack
childrents and need radical surgery, extensive, and chemotherapy which uncomfortable,
and that are challenge to be an orthopaedic for treating bone tumors. Because of that to be
general practitioner to impeach bone tumor will increase early diagnosis and good result in
the management.

1. Diagnosis of malign tissue tumors
2. Management of malign tissue tumors
SCENARIO
A 10 year old boy complaint about lump around his right knee accompanied with
erythema and pain. The lump and pain were beginning 4 months ago. He looks pale and
skinny. One week ago, he got slipped and fall, the pain is getting worst. After that, this
patient comes to you.
Learning task:
1. Make a complete history of this patient!
2. In physical examination what would you expect to find in this patient? After that,
what other you should do?
3. Please explain the radiograph of bone cancer?
4. Please explain about hysthopathologic of bone cancer ( osteosarcoma,
chondrosarcoma, ewing tumor etc)
5. What is metastase? How is the pathway of bone cancer metastase?
6. What is the principal of bone cancer treatment?
Self assessment:
1. Learn about primary and secondary bone cancer.
2. Learn about management of bone cancer, especially:
b. History taking
c. Radiographic
d. Biopsy
e. Treatment: Surgical and adjuvant
3. What is the commonest bone cancer you can find?
4. What is the differences of primary osteosarcoma and secondary osteosarcoma?

Day 18th
MODULE
21
BONE AND SOFT TISSUE INFECTIONS
dr. Wayan Suryanto Dusak, SpOT (K)
DR.dr. Eka Wiryanata SpOT (K)
AIMS:
infection of musculoscletal system
LEARNING OUTCOMES:
Osteomyelitis and Septic arthritis
1. Osteomyelitis
2. Septic arthritis
3. Tenosinovitis supuratif
ABSTRACTS
One of the most serious inflammatory disorders of the musculoskeletal system is

acute hematogenous osteomyelitis, a rapidly developing blood – borne bacterial infection of
bone and its marrow in children
The first and most significant symptom afflicted child experiences is severe and
constant pain near the end of the involved long bone. It’s extremely important to appreciate
that the early diagnosis of acute hematogenous osteomyelitis must be made on clinical
ground alone, because during at least the first week of illness, there is absolutely no
concrete radiographic evidence of bone infection
Acute hematogenous osteomyelitis represents an extremely serious infection that
demands urgents and vigorous treatment. As soon as the clinical diagnosis strongly
suspected, the child should be admitted to hospital for intensive treatment. In general, the
most effective treatment is bed rest and analgetics, supportive measures immobilization,
and antibacterial therapy
When pyogenic bacteria are invide a synovial joint, the result is acute septic
(pyogenic) arthritis. The most common source of septic arthritis in children is spreading of
pyogenic bacteria from hematogenous osteomyelitis. The general features and general
principles treatment of septic arthritis is similar to acute hematogenous osteomyelitis

1. Diagnosis of osteomyelitis
2. Management of osteomyelitis

SCENARIO
Five years old boy, came to the hospital with pain and swelling on his right hip after
fell down when he played 3 days ago. The child un willingness to use his limb and within 24
hours appears acutely ill:
1. What you assessment for this patient?
2. What is your diagnosis?
Learning task:
1. General features of inflammatory process of the musculoskeletal tissue
2. Etiology of AHO and septic arthritis
3. Pathogenesis and clinical features of AHO and SA
4. Treatment AHO and SA
5. Complication of AHO and SA
6. Describe sbout Tenosynovitis suppuratif
Self Assessment I:
1. Please explain the definition and sign and symptoms of bone infection
2. Please explain the infection route in bone and cartilage
3. Please explain the osteomyelitis classification
Self Assessment II:

1. Please explain the radiologic findings of osteomyelitis

Day 19th
MODULE
22
BONE AND IMUNOLOGY DISORDERS
(OSTEOARTHRITIS AND GOUT ARTHRITIS)
Prof. Dr. dr. Tjok Raka Putra, Sp.PD
AIMS:
imunologis disorder.
LEARNING OUTCOMES:
osteoarthritis
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.

1. Diagnosis of Osteoarthritis
2. Management of osteoarthritis
3. Diagnosis of gout arthritis
4. Management of gout arthritis

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
Gouty arthritis/Pseudo 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.

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?

Day 20th
MODULE
24
NSAID AND MUSCLE RELAXANT
dr. I.B. Ngurah, M.Kes
AIMS:
Describe the pharmacologic of NSAID and muscle relaxant
LEARNING OUTCOMES:
1. Describe the classification of NSAID, toxicity and interaction
2. Describe the classification of muscle relaxants, toxicity and interaction
1. Classification the anti-inflammatory drugs, drugs used in Gout
2. Mechanism of actions of the NSAIDs, acetaminophen and drugs used in Gout
3. Pharmacokinetics of the NSAIDs and drugs used in Gout
4. Clinical used of the NSAIDs and drugs used in Gout
5. Toxicities of the NSAIDs and drugs used in Gout
6. Drug drug interactions of the NSAIDs
7. Pharmacologic aspects of Celecoxib, Rofecoxib, Meloxicam, Diclofenac, Diflunizal,
Etodolac, Ibuprofen, Indomethacine, Mefenamic acid, Naproxen, Piroxicam
8. Classification the Disesase-Modifying, Slow-Acting Antirheumatic Drugs (DMARDS,
SAARDS)
ABSTRACT
The treatment of patients with inflammation involves two primary goals : first, the
relief of pain, which is often the presenting symptom and the major continuing complaint of
the patient; and second, the slowing or- in theory- arrest of the tissue-damaging process.
Reduction of inflammation with nonsteroidal antiinflamatory drugs (NSAIDs) often results in
relief of pain for significant periods. Furthermore, most of the nonopioid analgesics (aspirin,
etc) also have anti-inflammatory effects, so they are appropriate for the treatment of both
acute and chronic inflammatory conditions.
The glucocorticoids also have powerful anti-inflammatory effects and when first
introduced were considered to be the ultimate answer to the treatment of inflammatory
arthritis. Unfortunately, the toxicity associated with chronic corticosteroid therapy inhibits
their use except in the control of acute flare ups of joint disease. Therefore, the nonsteroidal
antiinflamatory drugs have assumed a major role in the treatment of arthritis.
Another important group of agents are characterized as slow-acting antirheumatic
drugs (SAARDs) or disesase-modifying antirheumatic drugs (DMARDs). They may slow the
bone damage associated with rheumatoid arthritis and are tought to affect more basic
inflammatory mechanism than do the NSAIDs. Unfortunately, they may also be more toxic
than the nonsteroidal anti-inflammatory agents.

1. Type of NSAID

2. Pharmacology of NSAID
3. Type of muscle relaxant
4. Pharmakologic of muscle relaxant
SCENARIO :
A 60-year-old woman complains with intense painful, warmth, redness and great
swollen in the first toe her right foot. Examination of fluid from the inflammed joint revealed
crystals of uric acid. The physician diagnosed the patient as acute attack of Gout.
1. Classify the treatment strategies in Gout arthritis
2. Explain the choice treatment for acute attack of Gout
3. List the toxicities drugs for acute attack of Gout
Learning Task:
1. Classify the anti-inflammatory drugs and drug used in Gout (Trevor, page 307)
2. Describe the mechanism of actions NSAIDs, Acetaminophen and drugs used in
Gout (Trevor, page 307, 311)
3. Explain the pharmacokinetics of theNSAIDs (Trevor, page 308)
4. List the toxicities of the NSAIDs (Trevor, page 309)
5. Describe the clinical used of the NSAIDs (Trevor, page 308)
6. Describe the advantages of the COX2 inhibitor compare with non selective
NSAIDs (Trevor, page 309)
7. List the toxicities of the COX2 selective inhibitor (coxibs), why? (Lecture,
Katzung, page 583)
8. Explain the interaction of the NSAIDs and drugs used in Gout with other drugs
ollowing drugs (Trevor, page 313)
9. Describe the pharmacologic aspects of the Celecoxib, Rofecoxib, Meloxicam,
Diclofenac, Diflunizal, Etodolac, Ibuprofen, Indomethacine, Mefenamic acid,
Naproxen, Piroxicam (Katzung, page 582-587)
10. Classify of the Disease-Modifying, Slow-Acting Antirheumatic Drugs (DMARDS,
SAARDS) (Trevor, page 309)
11. List the toxicities of the glucocorticoid (Katzung, page 594-595)
12. How to use the glucocorticoid in rheumatoid arthritis (Lecture, Katzung, page
594)
Self Assessment:
1. Which of the drugs do not have anti-inflammatory effect
A. Ibuprofen
B. Mefenamic acid
C. Acetaminophen
D. Aspirin
E. Naproxen
2. What’s the toxicity of phenylbutazone ?
A. Vertigo
B. Reye’s syndrome
C. Miosis
D. Aplastic anemia
E. Hypotention
3. Which of the drugs do not have gastric irritation
A. Aspirin
B. Phenylbutazone
C. Diclofenac
D. Celecoxib
E. Mefenamic acid
4. Aspirin overdose is characterized by a syndrome of
A. Fulminant hepatic failure

B. Acute renal failure

C. Bone marrow suppression
D. Metabolic acidosis
E. Encephalopathy
5. Which of the drugs do not have Disease-Modifying Antirheumatic Drugs
A. Chlorambucil
B. Cyclosporine
C. Methotrexate
D. Flurbiprofen
E. Chloroquine
SKELETAL MUSCLE RELAXANTS
CURRICULUM CONTENT
- definition
- classification and prototypes
- pharmacokinetics
- pharmacodynamics
- antidote
- toxicity
- interactions
ABSTRACT
Contraction of skeletal muscles is voluntarily controlled by impulses that originate in
the central nervous system (CNS). Impulses from the brain are conducted through the
spinal cord to the somatic motor neurons. Somatic motor neurons eventually connect with
skeletal muscle fibers forming a neuromuscular junction. The neuronal endings of the
somatic motor fibers contain the neurotransmitter acetylcholine (ACH). When ACH is
released into the neuromuscular synapses, it has interaction with cholinergic receptors
known as nicotinic –II (NII) receptors.
Depolarization of the muscle fibers occurs when ACH has interaction with the NII
receptors. Following depolarization, the contractile elements of the muscle fibers (actin and
myosin) produce muscle contraction. Muscle relaxation occurs after ACH is hydrolyzed by
acetylcholinesterase, this terminates the action of ACH.
A variety of neuromuscular blocking agents with varying mechanism of blockade and
pharmacokinetic properties are used to produce muscle relaxation during anesthesia.
Centrally acting muscle relaxants (Baclofen, Carisoprodol, Chordiazepoxide, Chlorphenesin
Carbamate, Diazepam, and Tizanidine) are drugs that relax skeletal muscle by a central
mechanism depress reflex impulse conduction within the spinal cord. Peripherally acting
skeletal muscle relaxants are drugs that inhibit skeletal muscle contraction by interfering
with NII receptors. There are two types of neuromuscular blockers: nondepolarizing (curare,
gallamine and pancuronium) and depolarizing (succinylcholine). Direct acting muscle
relaxants (dantrolene) are drugs that inhibits the skeletal muscle fiber by prevents actin and
myosin contraction.
Standard References
1. Trevor A.J., Katzung B.G.,and Masters S.B., : Katzung & Trevor’s

Pharmacology, 7th Ed. New York, Mc Graw-Hill/Lange., 2005, pp. 244-251
Additional Reading
1. Katzung, B.G.Basic & Clinical Pharmacology, 9th ed, New York, McGraw-
Hill/Lange, 2004 pp.446-462

2. Taylor, P. Agents Acting at Neuromuscular Junction and Autonomic Ganglia in

Goodman & Gilman’s The Pharmacological Basis of Therapeutics. 10th Ed.
Editor: Hardman, J.G., Limbird L.E., and Gilman, A.G. New York, Mc Graw-
Hill/Lange., 2001, pp.193-214
3. Hitner, H., and Nagle, B. Basic Pharmacology, 4th Ed. Singapura, Mc Graw-
Hill/Glencoe. 2002,pp.103-115
SCENARIO :
Mrs. Anita , 45 years old, come to Sanglah Hospital because she had traffic
accident. Doctor in hospital told her that she will have knee surgery. A note on her chart
indicates that she will be given succinylcholine during the operation to relax the muscles in
her leg. Her chart also indicates that she takes digitalis for a heart problem.
Learning task:
1. Assume that you work in a surgical unit where you coordinate patient medications,
identify a potential drug problem in case above and how it might be avoided
2. Explain mechanism action of succinylcholine as peripherally acting skeletal muscle
relaxants
3. Describe at least two ways in which skeletal muscles may be relaxed
4. Describes drugs that reduce the contraction of skeletal muscles affecting posture
and motor function
5. Compare the mechanism of action between depolarizing and non depolarizing
skeletal muscle relaxants
6. List three potential adverse effect associated with muscle relaxants
Self assessment:
1. What are the physiological events that precede skeletal muscle contraction?
2. What adverse effects are produced by the skeletal muscle relaxants as a result of
histamine release?
3. How does dantrolene differ from neuromuscular blockers?
4. What is the mechanism action of centrally acting skeletal muscle relaxants?
5. When are centrally acting skeletal muscle relaxants used?

REFERENCES
1. Essential Clinical Anatomy, 2nd ed, Keith L. Moore and Anne M.R.Agur, Lippincott
William & Willems, Philadhelpia, 2002, pp. 10 - 26
2. Bloom & Fawcett’s Concise Histology, 2nd ed, Fawcett D.N., Jensh, R.P, London,
2002, pp. 79 - 115
3. Textbook of Medical Physiology, 10th ed, A.C. Guyton, Hall, Philadelphia, WB
Saunders Co, 2000, pp. 52 – 95
4. Medical Biochemistry, Baynes J and Dominiczak, London, 1999, pp 497 - 509
5. Katzung & Trevor’s Pharmacology, Examination & Board Review, 6th ed. A.J. Trevor,
B.G. Katzung, Susan B Masters, pp. 322 – 330, 244 – 251.
6. Robbins Basic Pathology, 7th ed, Kumar V, Cotran RS, Robbins SL. WB Saunders,
Philadelphia, 2003, pp. 3 – 31; 756 – 787
7. Textbook of disorder and injuries of the musculoskeletal system, Robert B. Salter
MD
8. Apley’s system Orthopaedics and Fractures. Apley, Solomon, pp 25, 44, 52, 75, 101,
349, 427, 477.
9. Harrison’s, 16th ed. 2005. pp 2029 – 2036
ADDITIONAL TEXTBOOK
10. Review of Medical Physiology, 10th ed, W.F. Ganong, California : LANGE Medical
Publications.
11. Human Physiology – An Integrated Approach. 2nd ed. Silverthorn, 2001New
Jersey : Prentice-Hall Inc.
12. Pocket Companion to Textbook of Medical Physiology, 10th ed, A.C. Guyton,
Hall, Philadelphia, WB Saunders Co, 2000, pp. 52 – 95

Day 20th
MODULE
25
BONE FORENSIC
dr. Ida Bagus Putu Alit, Sp.F, DFM
AIMS:
Describe personal identity and pathological changes from skeleton
LEARNING OUTCOMES:
Describe personal identity and pathological changes from skeleton
a. Animal bone
b. Human bone
c. Age of human bone
ABSTRACTS
Examination of Human Skeletal can provide important information to determine the

identity of decease. The necessity for the identification of a decreased individual not only
fulfill a legal obligation which may be down in law, but recognize the fundamental right of all
individual to have an identity both in life and after death.
The doctor must collect information that will established the identity, the time of
death, the cause of death and the manner or mode of death (homicide, suicide, accidental
or natural).
In identification process, the doctor have task to establish: 1). The Human or non
human skeletal, 2). the number of deceased, 3). General identification of the skeletal
(gender, race, age, stature etc) and specific traits of the bone.
Human or non human skeletal can be established by gross anatomy, histology
appearances and x-ray examination. The gender and race can be determined by
examination of many bones especially skull, pelvic bone and long bones. The age can be
estimated by the changes pattern of ectocranial sutures, pubic symphysis and pre auricular
surfaces.
The cause of death (COD) and the manner of death (MOD) can be established only
if the trauma implicated the bone or related poison can be detected on bone.

1. The role of bone forensic
2. International protocol analysis
3. Medicolegal aspect of violence

SCENARIO
Case 1
Skeletal was found by a farmer in the field and reported to police immediately. After
that, police came to secure the skeletal and did an investigation. From the investigation,
police found that the skeletal was 35 year old Indonesian female, Type A Blood, height
149cm. The victim had already given birth twice with history of normal labor. Police asked
for medical examination afterwards. The doctor, who examined, found that the skeletal was
complete human skeletal.
1. What’s the purpose of this investigation?
2. a. To do bone sexing, the most accurate criteria can be seen from pelvic and cranium
bone. Please mention the characteristic of the cranium and pelvic bone based on their
gender.
b. Beside cranium and pelvic bone, gender can also be determined from the other long
bones. What are the differences of the long bones at each gender?
3. Race can be determined based on the characteristic of the skeleton and race indexes
a. Please mention the race characteristics seen on their skeleton
b. Please explain about cephalic indexes and pos-cranial indexes in determining race
4. Bone aging based on skeletal appearance can be evaluated from its ossification center,
teeth eruption, suture closure, symphisis appearance and preauricular surface. Please
mention and explain about bone aging.
5. Besides determining sex and age, pelvic bone can also be used to determine parturitas.
What’s the characteristic of parturitas on the pelvic bone? How’s the process happened?
6. How to determine blood type from the skeleton?
Case 2:
A 40 year old male was hit with a block wood at the right thigh during a fight.
Examination revealed wound and closed fracture femur at middle 1/3th
1. The fracture can be seen with 2 aspects, medical and judicial. What are those terms
means ?
2. Please explain in medicolegal aspect of the fracture.
3. Please define the qualification of the fracture and the reason for the qualification
4. What are the purpose of fracture qualification in the conclusion of visum et repertum
Learning Task:
1. Student know about international protocol analysis
2. Student know about bone and bone change according to age
3. Student know about medicolegal aspect of violence
Self AssessmentI:
1. Can we determine bone age?
2. Can we differentiate between human bone and animal bone?
Self Assessment II:

1. What’s the meaning of visum et repertum?

STUDENT PROJECT
MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS
2016
_______________________________________
Modul No : ..........
Topics : .....................................................................................
Lecturer : .....................................................................................
Competencies related to SKDI : __________________________________ Level 1 2 3A 3B

4 (Choose one)
Synthesis :
Facilitator
______________

SCORE OF STUDENT PROJECTMUSCULOSKELETAL SYSTEM AND CONNECTIVE

TISSUE DISORDERS
2016
_______________________________________
Group : ..........
Class : .....................................................................................
Facilitator : .....................................................................................
Dear Facilitators,
Please observe, appraise and give score to student project of the student in this groups foolowing the
criteria as belows.
No NIM Name Complete Writing Time
10
11
12
Att :
- Complete : content of synthesis related to SKDI and learning task
- Writing : handwriting and easy to read (clear)
- Time : complete and show the task to facilitator according to lecture's
schedule
Score range : 1 - 10
Facilitator
______________

Topics Student Project
1. Tendon Achilles Disorders
2. Nekrosis Caput Femur
3. Spondilolisthesis
4. Teratoma Sakrococygeal
5. Fraktur dan Dislokasi Tulang Belakang
6. Displasia Panggul
7. Shoulder Dislocation
8. Hip Dislocation
9. Fraktur Terbuka
10. Genu Varum &Valgum
11. Congenital Talipes Equino Varus (CTEV)
12. Leg Ulcers
13. Spondilitis
14. Medial & Lateral Epicondylitis
15. Fraktur Clavicula
16. Instabilitas sendi tumit
17. Trigger finger n Dequarvein disease
18. Carpal & Cubital Tunnel Syndrome
19. Scoliosis
20. Shoulder Impingement Syndrome & Frozen shoulder
21. Lesi Meniskus, Medial dan Lateral

Musculoskeletal Tayang Semester IV Tayang 22 Pebruari FIX

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Study Guide Musculoskeletal System and Connective Tissue Disorders

Faculty of MedicineUdayanaUniversity, MEU 1

Udayana University Faculty of Medicine,DME 2

Udayana University Faculty of Medicine,DME 3

Planners and Resource Persons

No Name Department Phone

1 Prof.Dr. dr. Putu Astawa, Sp.BO, M.Kes Surgery 0811392123

Udayana University Faculty of Medicine,DME 4

Dr. dr. Komang Januartha Putra 3rd floor:

dr. dr. luh Putu Ratna Sundari, 3rd floor:

Regular English (Class B)

dr. Ni Nengah Dwi Fatmawati, Sp.MK, 3rd floor:

Udayana University Faculty of Medicine,DME 5

Lecture Schedule 2018

Lecture : 10.00 – 11.00

1 10.00 – 11.30 09.00 – 10.00

11.30 – 12.00 12.00 – 12.30

Break 12.00 – 12.30 13.30 – 14.00

12.30 – 14.00 14.00 – 15.00

28/2 12.00 – 12.30 11.30 – 12.00

1/3 12.00 – 12.30 11.30 – 12.00

Self Assessment and Student Project dr. Mahendra Dewi

Udayana University Faculty of Medicine,DME 6

Lecture : 09.00 – 10.00

Self Assessment and Student Project

Break 12.00 – 12.30 11.30 – 12.00

Self Assessment and Student Project 12.30 – 14.00 13.30 – 15.00

Udayana University Faculty of Medicine,DME 7

Break 12.00 – 12.30 11.30 – 12.00

Self Assessment and Student Project

Break 11.30 – 12.00 12.00 – 12.30

Anatomy Dept. (1st

Anatomy Dept. (1st

Anatomy Dept. (1st

Udayana University Faculty of Medicine,DME 8

Break 11.30 – 12.00 12.00 – 12.30

Class Room : R. 3.02 (3rd Floor)

Udayana University Faculty of Medicine,DME 9

CLASS ROOM JOINT LAB

Group Distribution Member

REGULAR CLASS ENGLISH CLASS

EXAMINATION DAY : Monday, 2 April 2018

Udayana University Faculty of Medicine,DME 10

Students Meeting Representatives

Student project and Individual Learing

Udayana University Faculty of Medicine,DME 11

SELF DIRECTING LEARNING

Basic knowledge that must be known:

Udayana University Faculty of Medicine,DME 12

Udayana University Faculty of Medicine,DME 13

CTEV (Congenital Talipes Equinovarus).

Udayana University Faculty of Medicine,DME 14

DDH (Developmental Dysplasia of Hip)

SELF DIRECTING LEARNING

Basic knowledge that must be known:

Udayana University Faculty of Medicine,DME 15

2. Type of congenilat abnormalities

Udayana University Faculty of Medicine,DME 16

Udayana University Faculty of Medicine,DME 17

Sign and Diagnosis:

SELF DIRECTING LEARNING

Basic knowledge that must be known:

Udayana University Faculty of Medicine,DME 18