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Clinical Practice Keywords Skeletal system/Bone

physiology/Musculoskeletal health
Systems of life
Skeletal system This article has been
double-blind peer reviewed

In this article...
● T
 he key functions and structure of bone
● Bone formation and growth, and the process of remodelling
● Diet and lifestyle factors that can affect bone structure

Skeletal system 1:
the anatomy and physiology of bones
Key points
Author Jennie Walker is principal lecturer, Nottingham Trent University.
Bones are key to
providing the body Abstract The skeletal system is formed of bones and cartilage, which are connected
with structural by ligaments to form a framework for the remainder of the body tissues. This article,
support and the first in a two-part series on the structure and function of the skeletal system,
enabling movement reviews the anatomy and physiology of bone. Understanding the structure and
purpose of the bone allows nurses to understand common pathophysiology and
Most of the body’s consider the most-appropriate steps to improve musculoskeletal health.
minerals are stored
in the bones Citation Walker J (2020) Skeletal system 1: the anatomy and physiology of bones.
Nursing Times [online]; 116: 2, 38-42.
Diet and lifestyle can

T
affect the quality of
bone formation he skeletal system is composed of Protection
bones and cartilage connected by Bones provide protective boundaries for
After bones have ligaments to form a framework for soft organs: the cranium around the brain,
formed they the rest of the body tissues. There the vertebral column surrounding the
undergo constant are two parts to the skeleton: spinal cord, the ribcage containing the
remodelling l A
 xial skeleton – bones along the axis of heart and lungs, and the pelvis protecting
the body, including the skull, vertebral the urogenital organs.
Changes in the column and ribcage;
remodelling process l A
 ppendicular skeleton – appendages, Mineral homoeostasis
can result in such as the upper and lower limbs, As the main reservoirs for minerals in the
pathology such as pelvic girdle and shoulder girdle. body, bones contain approximately 99% of
Paget’s disease of the body’s calcium, 85% of its phosphate
bone or osteoporosis Function and 50% of its magnesium (Bartl and Bartl,
As well as contributing to the body’s 2017). They are essential in maintaining
overall shape, the skeletal system has sev- homoeostasis of minerals in the blood with
eral key functions, including: minerals stored in the bone are released in
l S
 upport and movement; response to the body’s demands, with
l P
 rotection; levels maintained and regulated by hor-
l M
 ineral homeostasis; mones, such as parathyroid hormone.
l B
 lood-cell formation;
l T
 riglyceride storage. Blood-cell formation (haemopoiesis)
Blood cells are formed from haemopoietic
Support and movement stem cells present in red bone marrow.
Bones are a site of attachment for ligaments Babies are born with only red bone
and tendons, providing a skeletal frame- marrow; over time this is replaced by
work that can produce movement through yellow marrow due to a decrease in eryth-
FRANCESCA CORRA

the coordinated use of levers, muscles, ten- ropoietin, the hormone responsible for
dons and ligaments. The bones act as stimulating the production of erythro-
levers, while the muscles generate the cytes (red blood cells) in the bone marrow.
forces responsible for moving the bones. By adulthood, the amount of red marrow

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Clinical Practice
Systems of life

flexibility to withstand the daily forces

Fig 1. Bone structure
exerted on them. This flexibility and ten-
sile strength of bone is derived from the
collagen fibres. Over-mineralisation of the
fibres or impaired collagen production can
Hyaline
cartilage Epiphysis increase the brittleness of bones – as with
the genetic disorder osteogenesis imper-
fecta – and increase bone fragility (Ralston
Epiphyseal line and McInnes, 2014).
Red bone
marrow Structure
Bone architecture is made up of two types
of bone tissue:
Marrow cavity
l C
 ortical bone;
l Cancellous bone.
Yellow bone
marrow Cortical bone
Also known as compact bone, this dense
outer layer provides support and protec-
tion for the inner cancellous structure.
Periosteum Diaphysis Cortical bone comprises three elements:
l Periosteum (Fig 1);
l Intracortical area;
l Endosteum (Bartl and Bartl, 2017).
The periosteum is a tough, fibrous
Nutrient
outer membrane. It is highly vascular and
foramen
Compact almost completely covers the bone, except
bone for the surfaces that form joints; these are
Site of covered by hyaline cartilage. Tendons and
endosteum
ligaments attach to the outer layer of the
periosteum, whereas the inner layer con-
tains osteoblasts (bone-forming cells) and
osteoclasts (bone-resorbing cells) respon-
sible for bone remodelling.
Spongy The function of the periosteum is to:
bone Epiphysis l P rotect the bone;
l H elp with fracture repair;
l N ourish bone tissue (Robson and
Syndercombe Court, 2018).
It also contains Volkmann’s canals,
small channels running perpendicular to
the diaphysis of the bone (Fig 1); these
has halved, and this reduces further to and 10% other proteins, such as glycopro- convey blood vessels, lymph vessels and
around 30% in older age (Robson and Syn- tein, osteocalcin, and proteoglycans (Bartl nerves from the periosteal surface through
dercombe Court, 2018). and Bartl, 2017). It forms the framework for to the intracortical layer. The periosteum
bones, which are hardened through the has numerous sensory fibres, so bone inju-
Triglyceride storage deposit of the calcium and other minerals ries (such as fractures or tumours) can be
Yellow bone marrow (Fig 1) acts as a poten- around the fibres (Robson and Synder- extremely painful (Drake et al, 2019).
tial energy reserve for the body; it consists combe Court, 2018). The intracortical bone is organised into
largely of adipose cells, which store triglyc- Mineral salts are first deposited between structural units, referred to as osteons or
erides (a type of lipid that occurs naturally in the gaps in the collagen layers with once Haversian systems (Fig 2). These are cylin-
the blood) (Tortora and Derrickson, 2009). these spaces are filled, minerals accumulate drical structures, composed of concentric
around the collagen fibres, crystallising and layers of bone called lamellae, whose struc-
Bone composition causing the tissue to harden; this process is ture contributes to the strength of the cor-
Bone matrix has three main components: called ossification (Tortora and Derrickson, tical bone. Osteocytes (mature bone cells)
l 2
 5% organic matrix (osteoid); 2009). The hardness of the bone depends on sit in the small spaces between the concen-
l 5
 0% inorganic mineral content the type and quantity of the minerals avail- tric layers of lamellae, which are known as
(mineral salts); able for the body to use; hydroxyapatite is lacunae. Canaliculi are microscopic canals
FRANCESCA CORRA

l 2
 5% water (Robson and Syndercombe one of the main minerals present in bones. between the lacunae, in which the osteo-
Court, 2018). While bones need sufficient minerals to cytes are networked to each other by fila-
Organic matrix (osteoid) is made up of strengthen them, they also need to prevent mentous extensions. In the centre of each
approximately 90% type-I collagen fibres being broken by maintaining sufficient osteon is a central (Haversian) canal

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Fig 2. Anatomy of cortical bone Box 1. Types of bones

l Long bones – typically longer than
Canaliculi they are wide (such as humerus,
radius, tibia, femur), they comprise a
Osteocyte diaphysis (shaft) and epiphyses at
Inner circumferential lamella
Lacuna the distal and proximal ends, joining
Lymphatic vessel
Osteon at the metaphysis. In growing bone,
Concentric lamellae
Outer this is the site where growth occurs
circumferential and is known as the epiphyseal
lamella growth plate. Most long bones are
Periosteum: Medullary located in the appendicular skeleton
Inner osteogenic cavity and function as levers to produce
layer movement
Outer fibrous l Short bones – small and roughly
layer
Trabeculae cube-shaped, these contain mainly
Central canal cancellous bone, with a thin outer
Perforating canal layer of cortical bone (such as the
bones in the hands and tarsal bones
Periosteal vein
in the feet)
Periosteal artery Spongy bone
l Flat bones – thin and usually slightly
Compact bone curved, typically containing a thin
layer of cancellous bone surrounded
by cortical bone (examples include
the skull, ribs and scapula). Most are
through which the blood vessels, lymph Blood vessels in bone are necessary for located in the axial skeleton and offer
vessels and nerves pass. These central canals nearly all skeletal functions, including the protection to underlying structures
tend to run parallel to the axis of the bone; delivery of oxygen and nutrients, homoeo- l Irregular bones – bones that do not
Volkmann’s canals connect adjacent stasis and repair (Tomlinson and Silva, fit in other categories because they
osteons and the blood vessels of the central 2013). The blood supply in long bones is have a range of different
canals with the periosteum. derived from the nutrient artery and the characteristics. They are formed of
The endosteum consists of a thin layer of periosteal, epiphyseal and metaphyseal cancellous bone, with an outer layer
connective tissue that lines the inside of the arteries (Iyer, 2019). of cortical bone (for example, the
cortical surface (Bartl and Bartl, 2017) (Fig 1). Each artery is also accompanied by nerve vertebrae and the pelvis)
fibres, which branch into the marrow cavi- l Sesamoid bones – round or oval
Cancellous bone ties. Arteries are the main source of blood bones (such as the patella), which
Also known as spongy bone, cancellous and nutrients for long bones, entering develop in tendons
bone is found in the outer cortical layer. It through the nutrient foramen, then
is formed of lamellae arranged in an irreg- dividing into ascending and descending
ular lattice structure of trabeculae, which branches. The ends of long bones are sup- ossification or endochondral ossification
gives a honeycomb appearance. The large plied by the metaphyseal and epiphyseal (replacing cartilage with bone).
gaps between the trabeculae help make the arteries, which arise from the arteries from Bones are classified according to their
bones lighter, and so easier to mobilise. the associated joint (Bartl and Bartl, 2017). shape (Box 1). Flat bones develop from
Trabeculae are characteristically ori- If the blood supply to bone is disrupted, membrane (membrane models) and sesa-
ented along the lines of stress to help resist it can result in the death of bone tissue moid bones from tendon (tendon models)
forces and reduce the risk of fracture (Tor- (osteonecrosis). A common example is fol- (Waugh and Grant, 2018). The term intra-
tora and Derrickson, 2009). The closer the lowing a fracture to the femoral neck, membranous ossification describes the
trabecular structures are spaced, the greater which disrupts the blood supply to the direct conversion of mesenchyme struc-
the stability and structure of the bone (Bartl femoral head and causes the bone tissue to tures to bone, in which the fibrous tissues
and Bartl, 2017). Red or yellow bone marrow become necrotic. The femoral head struc- become ossified as the mesenchymal stem
exists in these spaces (Robson and Synder- ture then collapses, causing pain and dys- cells differentiate into osteoblasts. The
combe Court, 2018). Red bone marrow in function. osteoblasts then start to lay down bone
adults is found in the ribs, sternum, verte- matrix, which becomes ossified to form
brae and ends of long bones (Tortora and Growth new bone.
Derrickson, 2009); it is haemopoietic tissue, Bones begin to form in utero in the first Long, short and irregular bones develop
which produces erythrocytes, leucocytes eight weeks following fertilisation (Moini, from an initial model of hyaline cartilage
(white blood cells) and platelets. 2019). The embryonic skeleton is first (cartilage models). Once the cartilage
formed of mesenchyme (connective tissue) model has been formed, the osteoblasts
Blood supply
FRANCESCA CORRA

structures; this primitive skeleton is gradually replace the cartilage with bone
Bone and marrow are highly vascularised referred to as the skeletal template. These matrix through endochondral ossification
and account for approximately 10-20% of structures are then developed into bone, (Robson and Syndercombe Court, 2018).
cardiac output (Bartl and Bartl, 2017). either through intramembranous Mineralisation starts at the centre of the

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Fig 3. Growth plate zones growth stops (Ralston and McInnes, 2014).
Males are on average taller than females
because male puberty tends to occur later,
Changes in so male bones have more time to grow
Growth plate zones
chondrocytes (Waugh and Grant, 2018). Over-secretion of
human growth hormone during child-
Resting or hood can produce gigantism, whereby the
quiescent zone Matrix production person is taller and heavier than usually
expected, while over-secretion in adults
results in a condition called acromegaly.
Growth or If there is a fracture in the epiphyseal
proliferation zone Mitosis growth plate while bones are still growing,
this can subsequently inhibit bone growth,
resulting in reduced bone formation and
the bone being shorter. It may also cause
misalignment of the joint surfaces and
cause a predisposition to developing sec-
ondary arthritis later in life. A discrepancy
Hypertrophic zone Matrix calcification in leg length can lead to pelvic obliquity,
with subsequent scoliosis caused by trying
to compensate for the difference.

Remodelling
Once bone has formed and matured, it
Calcification zone Cell death undergoes constant remodelling by osteo-
clasts and osteoblasts, whereby old bone
tissue is replaced by new bone tissue (Fig 4).
Primary Bone remodelling has several functions,
spongiosa including mobilisation of calcium and other
Zone of
ossification minerals from the skeletal tissue to main-
tain serum homoeostasis, replacing old
Secondary
spongiosa tissue and repairing damaged bone, as well
as helping the body adapt to different forces,
loads and stress applied to the skeleton.
Calcium plays a significant role in the
body and is required for muscle contrac-
cartilage structure, which is known as the this zone become ossified and form tion, nerve conduction, cell division and
primary ossification centre. Secondary part of the ‘new diaphysis’ (Tortora and blood coagulation. As only 1% of the body’s
ossification centres also form at the epi- Derrickson, 2009). calcium is in the blood, the skeleton acts as
physes (epiphyseal growth plates) (Dan- Bones are not fully developed at birth, storage facility, releasing calcium in
ning, 2019). The epiphyseal growth plate is and continue to form until skeletal maturity response to the body’s demands. Serum
composed of hyaline cartilage and has four is reached. By the end of adolescence around calcium levels are tightly regulated by two
regions (Fig 3): 90% of adult bone is formed and skeletal hormones, which work antagonistically to
l R esting or quiescent zone – situated maturity occurs at around 20-25 years, maintain homoeostasis. Calcitonin facili-
closest to the epiphysis, this is although this can vary depending on geo- tates the deposition of calcium to bone,
composed of small scattered graphical location and socio-economic con- lowering the serum levels, whereas the
chondrocytes with a low proliferation ditions; for example, malnutrition may parathyroid hormone stimulates the
rate and anchors the growth plate to the delay bone maturity (Drake et al, 2019; Bartl release of calcium from bone, raising the
epiphysis; and Bartl, 2017). In rare cases, a genetic muta- serum calcium levels.
l G rowth or proliferation zone – this tion can disrupt cartilage development, and Osteoclasts are large multinucleated
area has larger chondrocytes, arranged therefore the development of bone. This can cells typically found at sites where there is
like stacks of coins, which divide and result in reduced growth and short stature active bone growth, repair or remodelling,
are responsible for the longitudinal and is known as achondroplasia. such as around the periosteum, within the
growth of the bone; The human growth hormone (somato- endosteum and in the removal of calluses
l H ypertrophic zone – this consists of tropin) is the main stimulus for growth at formed during fracture healing (Waugh
large maturing chondrocytes, which the epiphyseal growth plates. During and Grant, 2018). The osteoclast cell mem-
migrate towards the metaphysis. There puberty, levels of sex hormones (oestrogen brane has numerous folds that face the
is no new growth at this layer; and testosterone) increase, which stops surface of the bone and osteoclasts break
FRANCESCA CORRA

l Calcification zone – this final zone of cell division within the growth plate. As down bone tissue by secreting lysosomal
the growth plate is only a few cells the chondrocytes in the proliferation zone enzymes and acids into the space between
thick. Through the process of stop dividing, the growth plate thins and the ruffled membrane (Robson and Syn-
endochondral ossification, the cells in eventually calcifies, and longitudinal bone dercombe Court, 2018). These enzymes

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musculoskeletal system, go to
Systems of life nursingtimes.net/orthopaedics

Physical exercise, in particular weight-

Fig 4. Bone remodelling process
bearing exercise, is important in main-
taining or increasing bone mineral density
Lining bone cells
and the overall quality and strength of the
bone. This is because osteoblasts are stim-
ulated by load-bearing exercise and so
bones subjected to mechanical stresses
Resting stage Bone formation undergo a higher rate of bone remodel-
Bone ling. Reduced skeletal loading is associ-
ated with an increased risk of developing
Osteoclasts Osteoclast osteoporosis (Robson and Syndercombe
recruitment Matrix
and activation synthesis Court, 2018).

Osteoblast Osteoblasts Conclusion

recruitment Bones are an important part of the muscu-
and activation
loskeletal system and serve many core
functions, as well as supporting the body’s
Bone resorption Transition structure and facilitating movement. Bone
Osteoclast removal
is a dynamic structure, which is continu-
ally remodelled in response to stresses
placed on the body. Changes to this remod-
dissolve the minerals and some of the bone disorganised bone remodelling affecting elling process, or inadequate intake of
matrix. The minerals are released from the one or more bones. Typical features on X-ray nutrients, can result in changes to bone
bone matrix into the extracellular space include focal patches of lysis or sclerosis, structure that may predispose the body to
and the rest of the matrix is phagocytosed cortical thickening, disorganised trabeculae increased risk of fracture. Part 2 of this
and metabolised in the cytoplasm of the and trabecular thickening. series will review the structure and func-
osteoclasts (Bartl and Bartl, 2017). Once the As the body ages, bone may lose some tion of the skeletal system. NT
area of bone has been resorbed, the osteo- of its strength and elasticity, making it
clasts move on, while the osteoblasts move more susceptible to fracture. This is due to References
Bartl R, Bartl C (2017) Structure and architecture
in to rebuild the bone matrix. the loss of mineral in the matrix and a of bone. In: Bone Disorder: Biology, Diagnosis,
Osteoblasts synthesise collagen fibres reduction in the flexibility of the collagen. Prevention, Therapy. Bit.ly/SpringerBoneDisorder
and other organic components that make Danning CL (2019) Structure and function of the
up the bone matrix. They also secrete alka- Diet and lifestyle factors musculoskeletal system. In: Banasik JL, Copstead
L-EC (eds) Pathophysiology. St Louis, MO: Elsevier.
line phosphatase, which initiates calcifica- Adequate intake of vitamins and minerals Drake RL et al (eds) (2019) Gray’s Anatomy for
tion through the deposit of calcium and is essential for optimum bone formation Students. London: Elsevier.
other minerals around the matrix (Robson and ongoing bone health. Two of the most Iyer KM (2019) Anatomy of bone, fracture, and
fracture healing. In: Iyer KM, Khan WS (eds)
and Syndercombe Court, 2018). As the important are calcium and vitamin D, but
General Principles of Orthopedics and Trauma.
osteoblasts deposit new bone tissue many others are needed to keep bones London: Springer.
around themselves, they become trapped strong and healthy (Box 2). Moini J (2019) Bone tissues and the skeletal
in pockets of bone called lacunae. Once system. In: Anatomy and Physiology for Health
Professionals. Burlington, MA: Jones and Bartlett.
this happens, the cells differentiate into
osteocytes, which are mature bone cells
Box 2. Vitamins and minerals Ralston SH, McInnes IB (2014) Rheumatology and

that no longer secrete bone matrix.

needed for bone health bone disease. In: Walker BR et al (eds) Davidson’s
Principles and Practice of Medicine. Edinburgh:
The remodelling process is achieved Key nutritional requirements for bone Churchill Livingstone.
Robson L, Syndercombe Court D (2018) Bone,
through the balanced activity of osteoclasts health include minerals such as calcium muscle, skin and connective tissue. In: Naish J,
and osteoblasts. If bone is built without the and phosphorus, as well as smaller Syndercombe Court D (eds) Medical Sciences.
appropriate balance of osteocytes, it results qualities of fluoride, manganese, and London: Elsevier
Tomlinson RE, Silva MJ (2013) Skeletal blood flow
in abnormally thick bone or bony spurs. iron (Robson and Syndercombe Court,
in bone repair and maintenance. Bone Research;
Conversely, too much tissue loss or calcium 2018). Calcium, phosphorus and vitamin 1: 4, 311-322.
depletion can lead to fragile bone that is D are essential for effective bone Tortora GJ, Derrickson B (2009) The skeletal
more susceptible to fracture. The larger sur- mineralisation. Vitamin D promotes system: bone tissue. In: Principles of Anatomy and
Physiology. Chichester: John Wiley & Sons.
face area of cancellous bones is associated calcium absorption in the intestines, Waugh A, Grant A (2018) The musculoskeletal
with a higher remodelling rate than cortical and deficiency in calcium or vitamin D system. In: Ross & Wilson Anatomy and Physiology
bone (Bartl and Bartl, 2017), which means can predispose an individual to in Health and Illness. London: Elsevier.
osteoporosis is more evident in bones with a ineffective mineralisation and increased
high proportion of cancellous bone, such as risk of developing conditions such as CLINICAL
the head/neck of femur or vertebral bones osteoporosis and osteomalacia. SERIES Skeletal system
(Robson and Syndercombe Court, 2018). Other key vitamins for healthy bones
Part 1: Anatomy and physiology
FRANCESCA CORRA

Changes in the remodelling balance may include vitamin A for osteoblast

of bones Feb
also occur due to pathological conditions, function and vitamin C for collagen Part 2: Structure and function of
such as Paget’s disease of bone, a condition synthesis (Waugh and Grant, 2018). the skeletal system Mar
characterised by focal areas of increased and

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