Osteomalacia

Question 1

What is Rickets/Osteomalacia?

Answer 1

Rickets in children and osteomalacia in adults are the manifestations of severe vitamin D deficiency.

Vitamin D deficicney leads to inadequate mineralisation of bone matrix. Vitamin D deficiency causes low calcium and phosphate, Osteomalacia results from a loss of skeletal mass caused by inadequate mineralisation of the normal osteoid tissue after the closure of the growth plates. Rickets results from the same underlying process, occurring in children and adolescents before the growth plates have closed.

Question 2

What are the causes of Osteomalacia?

Answer 2

A - Crohns/Coeliac (poor uptake)
M - Insufficient exposure to sunlight, nutritional deficiency, Severe dietary calcium deficiency can cause rickets despite adequate vitamin D
I - Liver/Renal Failure (defective Vitamin D sythenisis
C - Genetic Rickets
D - anticonvulsants, rifampicin, HAART

Question 3

What will you find on a history taking of Osteomalacia?

Answer 3

Symptoms:
Commonly No symptoms
Pain and proximal muscle weakness are the main features - Specifically then Rib, hip, pelvis, thigh and foot are typical.
Diffuse muscular aches and muscle weakness, including in the limbs and back
Low impact fractures
Poor growth or skeletal deformity in children

Risk Factors:
Dark skin
Obesity
Housebound or institutionalised.
Routine covering of the face and body
Vegetarianism
Increasing Age 

Specif Questions to ask?
Do they go outside much
Do the cover skin/use sun block 
Vegan?
Liver or renal problems?
Family histroy

Differentials:
Osteoporosis - Both can present with abnormal fractures, there will be no paion/msucle aches in osteoperosis
Pagets Disease of bone - No bony tenderness

Question 4

What will you find on examination of Osteomalacia?

Answer 4

End of the bed:
Pain in the hips may result in a waddling gait.

Affected Bones:
bone tenderness to percussion
poorly localised bony tenderness

Hands:
Proximal muscle weakness

Legs:
Proximal muscle weakness

Question 5

What investigations will you order in Osteomalacia?

Answer 5

Bedside:

Bloods:
Serum Caclium - Can be normal/low
serum 25-hydroxyvitamin D level - Will be low
Serum Phosphate - Can be low if cause is kidneys
UnE - To look at renal function
PTH - To rule out hyperparathyroidism
LFT - To look at liver funciton, ALP will be raised

Imaging:
X-Ray of affected areas - pseudofractures associated with sclerotic borders, which lie perpendicular to the cortical margins of bone
DEXA Scan

Question 6

What is the treatment of Osteomalacia?

Answer 6

Lifestyle:
Increase Vitamin D and Calcium uptake through diet and sunlight
1st Line - Vitamin D and Calcium Supplements
2nd Line - Vitamin D metabolites are utilised in patients who remain hypocalcaemic after treatment

Medical:
Treat any underlying factors