In the name of God

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In the name of God
In the name of God
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Osteomalacia

• Mohsen Mardani-Kivi
• Assistant Professor, Orthopedic Department,
  Guilan University of Medical Sciences

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Case

• 33 year old Asian lady
• Presents with 3 /12 months history of generalised
  bony pain
• PMH ?depression
• D/Hx ?sertraline
• P/Ex ? generalised bony tenderness
• Joints ? normal ROM, no inflammation

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Investigations

• Hb 12.9 (11.5-16.5) Calcium 2.18 (2.2-2.6)
• WBC 4.7 (4.9-11.0) Phosphate 0.79 (0.85-1.45)
• Plt 253 (150-400) Albumin 39 (35-50)
• ESR 12 Alk Phos 172 (25-96)
• Clotting Normal Total protein 72 (60-80)
• Urea 4.2 (3.0-6.5) LFTs normal
• Creat 85 (35-120)

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• Diagnosis?

THINK
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Definition

• Osteomalacia is the general term for the
  softening of the bones due to defective bone
  mineralization.

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Definition

• Osteomalacia in children is known as rickets, and
  because of this, it is often restricted to the
  milder, adult form of the disease.
• It may show signs as diffuse body pains, muscle
  weakness, and fragility of the bones.

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General characteristics

• Osteomalacia is derived from Greek
• osteo ?bone
• malacia ?softness
• most commonly found in
• dark-skinned
• diet-disbalanced subjects (mainly lactating
  females).
• Age adults
• Site WEIGHT-BEARING BONES such as vertebral
  bodies and femoral neck

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General characteristics
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Physiology

• Normal bone metabolism CA
• CALCIUM ? 99 in bone.
• Main functions ?muscle /nerve function, clotting.
• Plasma calcium? 50 free, 50 bound to albumin.
• Dietary needs
• Kids 600mg/day
• Adolescent 1300mg/day,
• Adult 750mg/day
• Pregnancy 1500mg/day,
• Breastfeeding 2g/day,
• Fractures 1500mg/day
• Absorbed in duodenum (active transport) and
  jejunum (diffusion), 98 reabsorbed in kidney
  prox. tubule, may be excreted in stool.

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Physiology

• Normal bone metabolism PHOSPHATE
• PHOSPHATE ? 85 in bone.
• Functions metabolite and buffer in enzyme
  systems.
• Plasma phosphate mainly unbound.
  Daily requirement 1-1.5g/day

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Physiology

• Regulation of Calcium Phosphate Metabolism
• Peak bone mass at 16-25 years.
• Bone loss 0.3- 0.5 per year (2-3 per year after
  6th decade).
• Parathyroid Hormone (PTH)
• Vitamin D3
• Calcitonin
• Other Hormones
  Estrogen Prevents
  bone loss
  Corticosteroids Increases
  bone loss
  Thyroid hormones Leads
  to osteoporosis
  Growth hormones
  Cause positive calcium balance
  
  Growth factors

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Physiology
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Physiology
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Physiology

• Serum Ca Phosphate in equilibrium with Ca
  Phosphate in bone.

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Physiology
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Patho physiology
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Patho physiology
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Etiology

• Calcium deficiency
• Hypo-phosphataemia
• Defect in Vitamin D metabolism
• Nutritional
• Diet oily fish, eggs, breakfast cereals
• Antacid abuse, causing reduced dietary phosphate
  binding
• underexposure to sunlight
• Elderly individuals with minimal sun exposure
• Dark skin, skin covering when outside

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Etiology

• Calcium deficiency
• Hypo-phosphataemia
• Defect in Vitamin D metabolism
• intestinal mal-absorption
• Coeliac
• Intestinal bypass
• Post-Gastrectomy
• Chronic pancreatitis
• Biliary disease (reduced absorption of Vitamins)
• Small bowel disease

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Etiology

• Calcium deficiency
• Hypo-phosphataemia
• Defect in Vitamin D metabolism
• liver kidney diseases
• Fat mal-absorption syndromes
• Kidney failure RTA, Renal osteodystrophy
• Epilepsy phenytoin, phenobarbitorate
• Genetic disease

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Etiology

• Other Etiologies
• Receptor Defects
• Altered phosphate homeostasis

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Pathology
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Symptoms Signs

• Bone pain , backache
• Muscle weakness
• Vertebral collapse kyphosis
• loss of height
• Deformities stress fractures

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Symptoms Signs

• Osteomalacia in adults starts insidiously as
  aches and pains in the lumbar region and thighs,
  spreading later to the arms and ribs.
• Pain is non-radiating, symmetrical, and
  accompanied by tenderness in the involved bones.
• Proximal muscles are weak, and there is
  difficulty in climbing up stairs and getting up
  from a squatting position

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Symptoms Signs

• Physical signs include deformities like lordosis.
• Pathologic fractures due to weight bearing may
  develop.
• Most of the time, the only alleged symptom is
  chronic and bony ache which is only revealed by
  pressure or shocks.

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Symptoms Signs

• Rickets 
• Tetanus , convulsions, failure to thrive
• restlessness, muscular flaccidity
• Flattening of skull (craniotabes)
• Thickening of wrists from epiphyseal overgrowth,
  Stunted growth, Rickety rosary, spinal curvature,
  Coxa vara, bowing,
• Fx of long bones
• Osteomalacia
• Aches and pains
• muscle weakness loss of height
• stress fx

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biochemistry

• Hypo-calcaemia
• Hypo-calcuria
• High alkaline phosphatase

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biochemistry
Work up for Osteomalacia

• Ca , P , Alk ph
• 24 h urinary Ca
• 25 (OH) Vit-D
• 1 , 25 (OH) Vit-D
• PTH
• Bone Biopsy

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biochemistry
1- ca P Nl Alk ph 2- ca
Nl P Alk ph 3- ca
P Alk ph

24 h Urinary ca lt 100 mg / 24 h 24 h Urinary
Hydroxyproline Excretion
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X-ray

• Rickets
• - Growth plate widening thickening
• - Metaphyseal cupping
• - Diaphyseal deformities
• Osteomalacia
• - Looser zone , biconcave vertebra , protrusio
  acetabuli
• - Spontaneous fractures
• Signs of secondary hyperparathyroidism

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X-ray

• Loosers zones
• incomplete stress Fx with healing lacking
  calcium, on compression side of long bones. 
• Codfish vertebrae due to pressure of discs
• Trefoil pelvis, due to indentation of acetabulae
  stress fx

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Loosers zones
X-ray
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X-ray
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X-ray
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Treatment

• Depends on the cause
• Nutritional
  Vitamin D
  deficiency
  Dietary chelators of calcium
  
  
• Phytates
  
• Oxalates
  Phosphorus
  deficiency (unusual)
• Antacid abuse

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Treatment

• Depends on the cause
• Gastro-intestinal absorption defects
  Post-gastrectomy
  
  Biliary disease
  
  Enteric absorption defects
  
• Short bowel syndrome
• Rapid onset (gluten-sensitive
  enteropathy) Inflammatory bowel
  disease
• Crohns
• Celiac

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Treatment

• Depends on the cause
• Renal tubular defects
  Vitamin D
  dependant
• type I
• type II
• Treatment High levels of vit D
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  Vitamin D resistant (familial hypophosphatemic
  rickets)
• Treatment Phosphate 1-3 gm
  daily, Vit D3 high dose
  Fanconi syndrome I, II, III
  Renal tubular
  acidosis

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Treatment

• Depends on the cause
• Renal Osteodystrophy in chronic renal failure
• Miscellaneous
  Hypophosphatasia
  
  Anticonvulsant therapy
• SURGERY
• For deformities

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Treatment
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Treatment

• Natural sources cheese, sardines, salmon, dark
  leafy vegetables sesame seeds.

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Any Questions?