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Support and Movement > Week 1 > Flashcards

Week 1 Flashcards

1
Q

What are the bio functions of the skeleton

A

provides framework
uses joints - motion
provides muscle leverage
protects organs

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2
Q

what are examples of non-mineralized CT

A

notochord and cartilage

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3
Q

what are examples of mineralized CT

A

calcified cartilage and bone

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4
Q

what is the notochord in vertebrate adults

A

nucelus pulpose in each intervertebral disc

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5
Q

what is cartilage

A

non-mineralized (lacks hydroxyapatite)
flexible - stronger under compression
easily injured & difficult to repair
growth tissue in fetus

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6
Q

what is cartilage composed of

A

gel matrix
collagen or elastic fibers
chondrocytes

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7
Q

what is calcified cartilage

A

mineralized (hydroxyapatite)
unorganized microstructure
stronger than cartilage
transitional tissue (EO)
calcification can be pathogenic

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8
Q

bone is a composite tissue made of____ and ___ components

A

organic components (osteoids - type I collagen and cells)
inorganic components (hydroxyapatite and water)

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9
Q

what is bone capable of

A

growth - only at surface
and remodeled throughout life

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10
Q

what are the physiological functions of bone

A

mineral reservoir
calcium homeostasis
source of blood cells
energy storage/source

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11
Q

what are the endocrine functions of bone

A

osteocalcin hormone
- insulin regulation
- brain development & function
- testosterone formation & release

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12
Q

what are the classifications of bone

A

long, short, flat, irregular

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13
Q

where do osteocytes live

A

in lacunae
between lamella surrounding haversian canals
connected to adjacent osteocytes by canaliculi

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14
Q

what are osteons

A

made of haversian canals surrounding lamella
contains vessels and nerves

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15
Q

what percent do bones get of total cardiac output

A

5-10%

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16
Q

where does endochondral bone grow from

A

cartilage precursor

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17
Q

where does endochondral bone form in

A

mesenchyme

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18
Q

where does ossification begin

A

in utero
- first in diaphysis
- then in epiphyses

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19
Q

what are the two ways bone is added to shaft

A
  • replacement of cartilage
  • conversion of perichondrium to periosteum
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20
Q

all EO-dervived bones have periosteal bone that forms concomitantly via

A

intramembranous ossification

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21
Q

how does membrane bone grow

A

no cartilage precursor
intramembranous ossification
grow outward

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22
Q

what is a sesamoid bone

A

bones that form within tendons
prevent muscle from deforming
improve muscle leverage

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23
Q

how is the skeleton held together

A

ligaments
joint capsules
menisci
bursae

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24
Q

what do synovial joints include

A

synovial fluid
synovial membrane
fibrous outer layer
capsular ligaments

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25
Q

what is menisci

A

cartilage spaces or pads

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26
Q

what is bursae

A

protective cushions
have synovial membrane and synovial fluid

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27
Q

what are the three types of joints

A

synovial
fibrous
cartilaginous

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28
Q

what is the most mobile joint

A

synovial joint

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29
Q

what are the different shapes of synovial joints

A

flat (plane)
barrel-shaped (hinge)
pivot
ball-and-socket

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30
Q

what are the types of motions that can occur at synovial joints

A

flexion
extension
pronation
supination
abduction
adduction
overextension
circumduction

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31
Q

which joint allows limited motion

A

fibrous joints

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32
Q

what are the three types of fibrous joints

A

sutures
syndesmoses
gomphosis

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33
Q

what is the least mobile joint

A

cartilaginous joints

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34
Q

what is synchondrosis

A

connected by cartilage

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35
Q

what is symphysis

A

multiple tissues together (sandwich)
bone-cartilage-CT-cartilage-bone

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36
Q

what is connective tissue

A

complex of cells and extracellular matrix that provides supporting and connecting framework for all other tissues of the body

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37
Q

what are the components of ECM

A

fibers and ground substance

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38
Q

what are the types of fibers

A

collagenous or fibrillar
reticular (non-fibril-forming collagens)
elastic (elasin)

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39
Q

what is in ground substance

A

glycosaminoglycans (GAGs)/Proteoglycans (PGs)
&
Structural glycoproteins

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40
Q

how is CT types and subtypes defined

A

according to amount, type, and proportions of ECM components

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41
Q

what are the properties of an individual collagen molecule

A
  • type II collagen
  • trimeric
  • rigid, rope-like
  • (+) charged (basic aa’s)
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42
Q

what are the properties of collagen fibril

A
  • composed of individual, quarter-staggered collagen molecules
  • eosinophilic
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43
Q

what are in GAG molecules

A

-chondroitin sulfate
- keratin sulfate (contains sulfate groups); highly (-) charge

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44
Q

what are the effects of ground substance being (-) charged

A
  • spread out
  • hydrophilic
  • basophilic
  • metachromatic
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45
Q

what makes up ground substance

A
  • hyaluronic acid (GAG)
  • link protein
  • core protein
  • PG molecule
  • GAG molecule
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46
Q

what is type II collagen

A
  • trimeric molecule
  • laterally aggregates into fibrils
  • fibrils criss-cross randomly
  • slightly basic, eosinophilic
  • slight positive charge
  • provides rigid structural support
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47
Q

what is PG/GAG aggregates

A
  • hyaluronic acid backbone
  • mainly chondroitin/keratan sulfate side chains (highly neg charge)
  • hydrophilic
  • basophilic, metachromatic stain
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48
Q

what is in hyaline cartilage

A
  • capillary
  • perichondrium
  • chondroblast
  • chondrocyte
  • collagen (type II) fibril
  • ground substance (sulfated proteoglycans)
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49
Q

is hyaline cartilage vascular or avascular

A

avascular

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50
Q

explain hydrated sponge concept in hyaline cartilage

A

can withstand compressive forces due to stabilizing collagen matrix, and ability of PG aggregates to bind or release water and allow matric to compress/expand

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51
Q

explain the molecular sieve concept

A

nutrient and gas exchange occurs via ECM and perichondrial blood vessels; ECM selectively sequesters various molecules/ factors

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52
Q

what is the formation of cartilage process called

A

chondrogenesis

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53
Q

what is the start of chondrogenesis

A

mesenchymal condensation

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54
Q

what is the second step in chondrogenesis

A

chondroblasts form
- divide and secrete ECM
- distance between neighboring cells increases

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55
Q

what is the third step of chondrogenesis

A

chondrocyte form
- cells surround entirely by ECM

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56
Q

what is the last step of chondrogenesis

A

isogenic groups
- as cells divide, daughter cells remain in close proximity, forming chondrocyte clusters

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57
Q

what is the matrix called that immediately surrounds chondrocytes

A

territorial matrix

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58
Q

what is the matrix called that is further away from chondrocytes

A

interterritorial matrix

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59
Q

what are the two mechanisms that cartilage grows by

A

apositional and interstitial

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60
Q

what is apositional cartilage growth mechanism

A

differentiation of chondroprogenitors and chondroblasts on the inner surface of the perichondrium into chondrocytes

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61
Q

what is interstitial cartilage growth mechanism

A

involves division of pre-existing chondrocytes within a cartilage matrix, giving rise to isogenous groups

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62
Q

what are the three cartilage types

A
  • hyaline cartilage
  • elastic cartilage
  • fibrocartilage
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63
Q

what is the function and location of hyaline cartilage

A

function: structural support, rapid growth, ability to withstand compression, temporary skeleton during embryogenesis

location: fetal skeleton, respiratory passages, cushioning of joints

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64
Q

what is the function and location of elastic cartilage

A

function: flexible support, ability to withstand deformation

location: external ear, auditory tubes, epiglottis, larynx cartilages

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65
Q

what is the function and structure of fibrocartilage

A

function: attachment to bone, provides restricted (type I and II) mobility under great mechanical stress

location: annulus fibrosus of intervertebral discs, pubic symphysis, bone-ligament junctions

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66
Q

where is fibrocartilage always found

A

in association with dense connective tissue

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67
Q

why does hyaline cartilage serve as a temporary skeleton during embyogenesis

A
  • ECM composition
  • enables hyaline cartilage to be firm and compressible
  • provide protection and structural support
  • grow increase rapidly by interstitial and apositional growth
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68
Q

how is this skeletal “blue-print” gradually replaced by trabecular bone and marrow

A

Endochondral ossification

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69
Q

why is endochondral ossification called the substitution process

A

ossification means formation of bone, endochondral means without cartilage

process is formation of bone within a cartilage blueprint within cartilage model

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70
Q

how are most skeletal elements neck down and a few skull bones formed in vertebrates

A

by EO

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71
Q

what is the EO outcome

A

gives rise to future skeletal elements that are going to have a bone marrow cavity where hematopoiesis takes place

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72
Q

describe the steps of EO in this picture

A
  1. skeleton initially comprised of hyaline cartilage that grows via intersitial and appositional growth
  2. at genetically predetermined stage, periosteal bony collage forms within perichondroum (via IO)
  3. as collar minerallizes, perichondrium becomes periostrum and compact bone is laid down on outer surface of shaft
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73
Q

describe steps of EO in this picture

A
  1. as periosteal bony collar extends to epiphysis, chondrocytes stack and then enlarge to ~10 fold in size (hypertrophy), hypertrophic cartilage beings to calcify
  2. presence of periosteal bony collar and calcified cartilage matrix inhibits oxygen and nutrient diffusion
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74
Q

describe EO in this picture

A
  1. diaphysis is penetrated by periosteal bud made up of blood vessels, mesenchymal cells, and chondro/osteoclasts - establishes the primary ossification center
  2. chondro/osteoclasts secrete enzymes that degrade hypertrophic cartilage, while mesenchymal cells differentiate into cells of primitve bone marrow and into osteoblasts
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75
Q

describe EO in this picture

A
  1. vascular invasion and gradual degradation of hypertrophic cartilage results in establishment of a marrow cavity and deposition of ostepblasts along hypertrophic cartilage remnants
  2. formation of secondary ossification center at the epiphyses defines 5 distinct growth plate cartilage zones
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76
Q

what are the 5 growth plate zone

A
  1. resting zone
  2. zone of proliferation
  3. zone of hypertrophy
  4. zone of degradation
  5. zone of ossification
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77
Q

describe EO in this picture

A

transition from hypertrophic cartilage to bone and marrow continues within growth plate and responsible for longitudinal growth

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78
Q

describe EO in this picture

A
  1. growth plate closure results in termination of longitudinal growth
  2. in adults the only cartilage (hyaline) that remains is the articular cartilage at the outer ends of (epiphyses) of bone
  3. carilage lacks perichondrium
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79
Q

what is the clinical significance of cartilage lacking perichondrium

A

reduced ability to repair itself
osteoarthritis

80
Q

what is the purpose of articular cartilage

A
  • low friction gliding surface
  • transmits weight bearing forces to underlying bone
  • withstand high cyclic loads
81
Q

what are the two ways articular cartilage can be damaged

A
  • abnormal loading (physical): cyclic trauma & direct
  • biochemical damage: inflammation
82
Q

what is an example of a predisposition to cartilage injury

A

canine hip dysplasia

some animals more predisposed

83
Q

what is canine hip dysplasia

A
  • improper alignment of the femoral head within the acetabulum
  • 3 mutations in glycoproteins, PG, fibrillar structure
  • abnormal mechanical stress
  • articular cartilage damage
84
Q

injury starts a cascade of inflammation and increase in ____

A

catabolism/degradation

85
Q

what are chondrocytes activated by

imbalance due to injury

A

stress

86
Q

what do chondrocytes act as

imbalance due to injury

A

their own inflammatory mediators

87
Q

what gets released when imbalance is caused due to injury

A

cytokines

88
Q

catabolic enzymes are released by ____

A

chondrocytes

89
Q

what do catabolic enzymes cause

A
  • collagen breakdown
  • proteoglycan breakdown
90
Q

what do catabolic enzymes result in

A

degradation of ECM

91
Q

what two processes happen in tissue repair

A
  • replacement of damaged cells and matrix
  • regeneration
92
Q

what are the general phases of tissue healing

A
  1. inflammation
  2. repair
  3. remodeling
93
Q

what is inflammation

tissue healing

A
  • vascular response
  • cellular infiltration
  • scaffold for repair
  • 3-5 days
94
Q

what is repair

tissue healing

A
  • cellular infiltration - fibroblasts
  • local cellular repsonse
  • 3 days - 2 weeks
95
Q

what is remodeling

tissue healing

A
  • removal of inferior tissue, replacement
  • 2 weeks - 1 year
96
Q

why is cartilage being avascular a problem in response to injury

A
  • different inflammatory phase
  • no scaffold
  • no cellular infiltration
  • limited repair
97
Q

why is fibrocartilage a problem in cartilage response to injury

A
  • GAG concentration decreased
  • Type 1 collegen put in
  • biomechanically inferior - reduced funtion
98
Q

what is intrinsic cartilage repair

A
  • no vascular ingrowth
  • relies on local chondrocytes
  • sub-par
99
Q

what is matrix flow

A
  • forms lips of cartilage from perimeter that migrates towards center of defect
  • surface chondrocytes are more fibroblast like
  • fibroblast > hyaline cartilage
  • heal small defects
100
Q

what is extrinsic cartilage repair

A
  • vascular ingrowth from surrounding tissue (bone)
  • mesenchymal elements from subchondral bone
  • helps form new CT
101
Q

what are the two major limitations of cartilage

A
  1. avascular
  2. inferior repair tissue
102
Q

osteoprogenitors

A

“stem cells” for bone
spindle shaped
found near bone surfaces in periosteum and endosteum

103
Q

bone lining cells

A

flattened
line bone surfaces
quiescent osteoblasts

104
Q

osteoblasts

A

“bone forming”
proliferative
cuboidal
appear as sheets on bone surface
deposit osteoid (unmineralized bone ECM)

105
Q

osteocyte

A

“mature” bone cells
non-proliferative
encased in mineral
extensive filopodia for monitoring Ca levels and communicating with osteoblasts and osteoclasts

106
Q

osteoclasts

A

“breakdown” or resorb bone
large
multinucleate
found on bone surface
not mesenchymal cells

107
Q

inorganic phase of bone is ___

A

mineral (hydroxyapatite) - 75%

108
Q

organic phase of bone is

A

type 1 collagen
small PG and glycoproteins - 25%

109
Q

in bone, initial mineral deposition occurs where

A

in hole zones of type 1 collagen molecules in a collagen fiber from 1/4 staggered arrangement

110
Q

do collagen fibers mineralize

A

no - this is why bones are able to bend

111
Q

osteogenesis

A

formation of bone; proceeds through EO and IO

112
Q

endochondral ossification

A
  • involves a hyaline cartilage model, which serves as a blueprint for the future skeleton and marrow
  • cartilage undergoes hypertrophy and is replaced by trabecular (spongy) bone, and bone marrow
113
Q

intramembranous ossification

A
  • involves a direct differentiation of mesenchymal/osteoprogenitor cells to osteoblasts, which secrete bone matrix
  • bone forms through appositional growth
  • end result: compact bone (membranous) without a marrow cavity
114
Q

what is primary bone

A
  • first bone that is laid down, regardless of whether it is formed by EO or IO - temporary immature skeleton
  • not well organized
  • greater cell-to-matrix ratio
115
Q

primary bone is replaced by mature ______ through ____ and _____

A

secondary bone, modeling, remodeling

116
Q

what is another term for secondary bone

A

lamellar bone

117
Q

lamellar bone is organized in functional units called ___

A

osteons

118
Q

what do osteons consist of

A
  • central Haversian canal w/ blood vessels and nerves
  • concentric lamellae of bone matrix
  • inhabiting cells
119
Q

what is bone remodeling

A
  • balance between osteoclasts degrading bone and osteoblasts depositing bone
  • OCLs create resorption pits
  • blood vessels invate pits and import osteoprogenitors that differentiate into osteoblasts
  • OBs align along exposed bone surface and secrete osteoid in lamellae around haversian canals
120
Q

what stage is bone in during skeletogenesis

A

modeling
- bone change width and shape
- primary to secondary

121
Q

what stage is bone in during adult-homeostasis

A

remodeling
- bone adapt to mechanical pressure
- Ca storage and release

122
Q

what stage is bone in during pathology

A

remodeling
- fracture repair
- Ca imbalance
- OB/OCL dysfunction

123
Q

what is woven bone

A

immature bone/temporary
- highly cellular
- random matrix organization
- rapid formation
- poorly mineralized
- weak

124
Q

what is lamellar bone

A

mature bone
- low cellularity
- organized
- slow formation
- strong
- well mineralized

125
Q

what is the difference between structure of lamellar and woven bone

A

rate of formation (time)

126
Q

where are sites of new “repair” bone formation

A
  • periosteum
  • endosteum
127
Q

traumatic fracture

A

normal bone broken by excessive force

128
Q

pathologic fracture

A

abnormal (diseased) bone broken by minimal trauma or during normal weight bearing forces

129
Q

avulsion

A

fractures that occur at site of ligament/tendon insertion

130
Q

articular

A

worse prognosis because of incongruent joint surface - secondary DJD

131
Q

what is direct (primary) healing

A
  • contact healing (surgical fixation)
  • gap healing (<1mm)
  • required rigid fracture stabilization
132
Q

what is indirect (secondary) healing

A
  • biomechanical environment dictates which type takes place
  • rigid, stable fixation vs limited intervention
133
Q

what are the stages of indirect bone healing

A
  • inflammation
  • repair (soft callus and bony callus)
  • remodel
134
Q

what will low O2 tension result in

A

hyaline cartilage formation which eventually turns into EO and radiopaque

135
Q

what are the 3 complications of fracture healing

A
  • excessive motion (fibrous non-union)
  • inadequate blood supply
  • infection = osteomyelitis
136
Q

necrotic (dead) bone is called

A

sequestrum

137
Q

the embryo develops in 3 germ layers ___

A

ectoderm, mesoderm, endoderm

138
Q

the ectoderm is responsible for forming the ___

A

nervous system and skin

139
Q

the mesoderm is responsible for forming the ____

A

musculoskeletal system and circulatory system

140
Q

the ectoderm is responsible for the ___

A

GI tract and other organs

141
Q

the ectoderm creates the ___ and ___ via ____

A

neural tube; neural crest cells; neurulation

142
Q

the mesoderm is divided into___

A

paraxial, intermediate, and lateral plate mesoderm

143
Q

somites form as sections of ___

A

paraxial mesoderm

144
Q

lateral plate mesoderm has two players called?

A

splanchnic and somatic

145
Q

the sternum is formed from

A

somatic player of lateral plate mesoderm

146
Q

what are somitocoels

A

“holes” form in the center of somites

147
Q

the somitocoel expants to cut somite into dorsal and ventral parts called

A

dermatomyotome and sclerotome

148
Q

the dermomyotome divides again into

A

dermatome, myotome, syndetome

149
Q

dermatome

A

makes skin

150
Q

myotome

A

makes muscle

151
Q

syndetome

A

makes tendon

152
Q

the sclerotome doesn’t divide and makes ___

A

bone via EO around neural tube and notochord

153
Q

vertebrae and ribs are created from

A

sclerotome

154
Q

there is a ___ and ___ portion of sclerotomes

A

rostral; caudal

155
Q

what is resegmentation

A

when the caudal portion of somite is fused with the rostral portion - allows intervertebral space for spinal nerves

156
Q

the sclerotome makes structures including:

A
  • vertebral arches w/ spinous process
  • vertebral body
  • transverse process
  • intervertebral discs
157
Q

what happens after resegmentation

A

each myotome becomes associated with 2 adjacent vertebrae and crosses the intervertebral space

158
Q

what is the intervertebral space

A
  • where the spinal nerve passes through and can innervate the muscles created by that myotome and provides sensory innervation to the skin
  • can trace sensory nerve fibers to spine
159
Q

what is the dorsolateral part of the myotome and what does it create

A

epimere; epaxial muscles (deep back muscles)

160
Q

what is the ventralmedial part of the myotome and what does it create

A

hypomere; hypaxial muscles (trunk/limb muscles)

161
Q

what are HOX genes

A

responsible for establishing patterning of vertebrae and limbs

162
Q

what are some consequences of homeotic mutations of HOX genes

A
  • flawed differentiation
  • polydactyly
  • syndactyly
163
Q

what are fibroblast growth factors (fgf) and what can result from mutations

A

cell signaling proteins; abnormal growth plate function (dwarfism)

164
Q

what can mutations in fibroblast growth factor receptors (fgfr) result in

A
  • FGFR3 = achondroplasia
  • FGFR1/2 = premature cranial synostosis
165
Q

what are TBX genes

A

determine which limbs are upper and lower (TBX 4 & 5)

166
Q

what does FGF10 lead to

A

continued growth of limb buds

167
Q

limb buds first grow from ___ and then from ___

A

ectoderm; somatic lateral of lateral plate mesoderm

168
Q

what is the thickened area on the tip of a limb bud called and what is it stimulated by and what does it secrete

A

apical ectodermal ridge (AER); FGF10; FGF4/8

169
Q

what is the part of the lateral plate mesoderm that is closest to the AER called

A

progress/proliferating zone (PZ)

170
Q

what is bone differentiation

A
  • as limb bud grows, growth factors are not as saturated in lateral plate mesoderm that is furthest away from AER
  • differentiate into cartilage then into bone (EO)
  • creates stylopod, zeuopod, and autopod
171
Q

some tissue at AER starts to undergo apoptosis because…

A
  • high levels of bone morphogenic protein (BMP) and retinoic acid
  • forms fingers
  • AER still proliferates to make digits
172
Q

AER dies off so they stop ___

A

proliferating and start differentiating into phalanges

173
Q

how do you get differentiation of the autopod

A
  • on dorsal portion of autopod there is zone of polarizing activity (ZPA)
  • drives directional development of autopod by releasing molecules that create a gradient (Sonic Hedgehog protein)
174
Q

how are limb muscles developed

A
  • myotome migration into ventral and dorsal condensation (portions)
  • syndetome migrates to make tendons
  • dermatome migrates to make skin
175
Q

what does ventral condensation create

A

forelimb
- flexor
- pronator

hindlimb
- extensor
- adductor
- digital extensor

176
Q

what does dorsal condensation create

A

forelimb
- extensor
- supinator

hindlimb
- flexor
- abductor
- digital flexor

177
Q

what are the somites toward the cranial end of the neural tube called

A

occipital somites

178
Q

neural crest cells and occipital somites create ___ around ______ with the brain

A

neurocranium; rostral end of neural tube

179
Q

what are the two types of bone in the skull

A

endochondral and membrane bone

180
Q

what does endochondral bone make up

A
  • chondrocranium
  • splanchnocranium
181
Q

what does membrane bone make up

A

dermatocranium

182
Q

how is membrane bone made

A

intramembranous ossification

182
Q

how is membrane bone made

A

intramembranous ossification

183
Q

what is chondro(osteo)dysplasia

A
  • congenital with defects present at birth
    –> cartilage/bone formation impacted (ex: chondrodsyplastic dwarfism vs OI)
    –> remodeling impacted (ex: OCL defect)
  • clinical manifestations can be immediate or delayed
184
Q

what are the causes of congenital skeletal abnormalities

A
  • genetic (HOX gene)
  • in utero exposures (toxin/nutritional)
185
Q

what is generalized chondrodysplasia

A

congenital defects involving the cartilage template and generalized defect in EO

186
Q

what are the origins of chondrodysplasias

A
  • defect in cartilage template required for EO (spontaneous or heritable mutations)
  • defects can be generalized or regional
187
Q

what does heritable mutations in chondrodysplasias cause

A

disproportionate (chondrodysplastic) dwarfism
- early DJD from malformations in shape of epiphysis = joint instability and incongruence

188
Q

what is K9 chondrodysplasia

A
  • chondrodysplastic
  • CFA18-FGF4
  • disproportionate dwarfism
    (shortened limbs/breed standard)
189
Q

what is K9 Chondrodystrophy

A
  • chondrodystrophic
    -CFA12-FGF4
  • shortened limbs
    -IVDD - IVD herniation - Neurologic signs
190
Q

what is bovine chondrodysplasia (Bulldog Calf syndrome)

A
  • shorted malformed limbs
  • skull malformations
191
Q

what are generalized osteodysplasia

A
  • cartilage ok
  • bone not ok
  • generalized deformities, monostotic or polyostotic malformations
192
Q

what is osteogenesis imperfecta

A
  • affects puppies, calves, lambs, humans
  • osteopenic disease (decreased bone density and increased bone fragility)
  • mutation in Type 1 collagen synthesis
193
Q

what is focal chondrodysplasias

A
  • developmental defects in EO at focal, repeatable sites
  • osteochondrosis (OC) and osteochondritis dissecans (OCD)
194
Q

what is OC and OCD

A
  • heterogeneous lesions in growth cartilage (epiphyseal)
  • dogs, horses, pigs, cattle, poultry
  • focal defect (delay or failure) of EO
  • bilaterally symmetrical (50%)
  • secondary osteoarthritis common
195
Q

what are the causes of OC/OCD

A

damage to vasculature in growth cartilage

196
Q

Equine OC is:

A

vascular necrosis - focal retained necrotic cartilage core - cartilage folds - subchondral bone trauma

Support and Movement (8 decks)

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