Osteo osteomalacia ricket2

OSTEO-OSTEO-POROSISPOROSIS

OSTEO-OSTEO-POROSISPOROSIS

Dr.Abdullah Al-OmranDr.Abdullah Al-Omran

NOTE : THIS PRESENTATION DOES NOT NOTE : THIS PRESENTATION DOES NOT REPLACE ATTENDANCE OR REPLACE ATTENDANCE OR

INFORMATION GIVEN IN THE INFORMATION GIVEN IN THE LECTURE.IT IS INTENDED AS A LECTURE.IT IS INTENDED AS A

HIGHLIGHT FOR THE TOPICHIGHLIGHT FOR THE TOPIC

OSTEOPOROSISOSTEOPOROSIS


DEFINITION DEFINITION

WHO Definition 1994:WHO Definition 1994:

A skeletal disease characterized by A skeletal disease characterized by low bone mass low bone mass and and deterioration of the microarchitecture of bone tissue with a deterioration of the microarchitecture of bone tissue with a consequent consequent increase in bone fragilityincrease in bone fragility and susceptibility to and susceptibility to low trauma fractures. low trauma fractures.

Why? Imbalance between osteoblast & osteoclast functionWhy? Imbalance between osteoblast & osteoclast function




INCIDENCE:INCIDENCE: 1 in 3 women and 1 in 12 men. 1 in 3 women and 1 in 12 men.

TYPES :TYPES :

I.I. (postmenoposal): thin trabicular bone(postmenoposal): thin trabicular bone

55-75y55-75y

f:m 6:1f:m 6:1

II.II. Senile : thin both trabicular & cortical boneSenile : thin both trabicular & cortical bone

70-85 y70-85 y

2:12:1


RISK FACTORS + CAUSES :RISK FACTORS + CAUSES :!!I.POST MENOPOSAL & SENILE (primary)I.POST MENOPOSAL & SENILE (primary) -sessation of estrogen or androgen-sessation of estrogen or androgen - bad nutritional habits during productive years (15-45yr)- bad nutritional habits during productive years (15-45yr) (low calcium content food , smoking,alcohol,soda drinks.(low calcium content food , smoking,alcohol,soda drinks. - genetics (inheritance) & race (cocasian female)- genetics (inheritance) & race (cocasian female)

II.Secondary :II.Secondary :1.medications: steroids,chronic heparin use,anticonvusants,chemotherapy.1.medications: steroids,chronic heparin use,anticonvusants,chemotherapy.2.immobilisation2.immobilisation3. Medical conditions3. Medical conditions: : Anorexia Nervosa, RA, Early Anorexia Nervosa, RA, Early

menopause,Hyperthyroidism, hyperparathyroidism, hypogonadism menopause,Hyperthyroidism, hyperparathyroidism, hypogonadism Transplantation, Cushings disease/syndrome, Transplantation, Cushings disease/syndrome, Chronic kidney, lung or GI diseases Chronic kidney, lung or GI diseases


Clinically:Clinically:

P?P?

P?P?



INVESTIGATIONSINVESTIGATIONS

1.1. History for risk factors History for risk factors

2.2. Physical examination Physical examination

3.3. X-ray of lumbar and thoracic spine. X-ray of lumbar and thoracic spine. Although >30 % of bone loss required to be visible on X-ray, Although >30 % of bone loss required to be visible on X-ray, there may be some asymptomatic wedge #s there may be some asymptomatic wedge #s

4.4. Bone mineral Density measurement Bone mineral Density measurement

5.5. Blood tests, FBC, ESR, serum biochemistry Blood tests, FBC, ESR, serum biochemistry

6.6. Testosterone and Gonadotrophin levels in men Testosterone and Gonadotrophin levels in men


The Gold standard test in clinical practice is measurement of The Gold standard test in clinical practice is measurement of Bone Mineral Density (g/cm3), of the vertebral spine and Bone Mineral Density (g/cm3), of the vertebral spine and the hip. This is as recommended by the National the hip. This is as recommended by the National Osteoporosis society. Only vertebral measurements can be Osteoporosis society. Only vertebral measurements can be used to assess effectiveness of treatment at present. used to assess effectiveness of treatment at present.

1.1. DEXA scansDEXA scans

2.2. Radiographic AbsorptiometryRadiographic Absorptiometry

3.3. Single Photon X-ray absorptiometry (SPA)Single Photon X-ray absorptiometry (SPA)

4.4. Quantitative Computer tomographyQuantitative Computer tomography

5.5. Quantitative UltrasoundQuantitative Ultrasound


OSTEOPOROSIS OSTEOPOROSIS

PREVENTATIVE MEASURES PREVENTATIVE MEASURES

Aims- to achieve an adequate peak bone mass, by ?Aims- to achieve an adequate peak bone mass, by ?


TREATMENT OF ESTABLISHED OSTEOPOROSIS: TREATMENT OF ESTABLISHED OSTEOPOROSIS: CALCIUM + VIT. D SUPPLEMENTS CALCIUM + VIT. D SUPPLEMENTS

Minimum daily intake of calcium should be achieved. Minimum daily intake of calcium should be achieved. Should only be prescribed if this is not achieved by diet. Should only be prescribed if this is not achieved by diet.

Vit D in all elderly institutionalized osteoporotics is Vit D in all elderly institutionalized osteoporotics is recommended. recommended.

RDA Calcium = 1400 mg RDA Calcium = 1400 mg RDA Vit. D = 600-800 IU. RDA Vit. D = 600-800 IU.

biphos

OSTEOPOROSIS OSTEOPOROSIS

HRT (OESTROGEN): HRT (OESTROGEN): Prevent osteoporosis and slows or reverses progression. Prevent osteoporosis and slows or reverses progression. Given at doses equivalent to 0.625mg of Premarin, it will Given at doses equivalent to 0.625mg of Premarin, it will

increase bone density by 2% per year. increase bone density by 2% per year. Given for 5-10 years almost halves the risk of fractures. Given for 5-10 years almost halves the risk of fractures. Has a role in corticosteroid induced osteoporosis Has a role in corticosteroid induced osteoporosis

ContraindicationsContraindications: Endometrial carcinoma, Breast cancer, : Endometrial carcinoma, Breast cancer, undiagnosed vaginal bleeding. undiagnosed vaginal bleeding.

Other benefits: loss of menopausal symptoms, cardiovascular Other benefits: loss of menopausal symptoms, cardiovascular protection. protection.


BISPHOSPHONATES: BISPHOSPHONATES: Synthetic analogues of inorganic pyrophosphate. Inhibit bone Synthetic analogues of inorganic pyrophosphate. Inhibit bone

resorption by osteoclasts resorption by osteoclasts Alendronate (Fosamax) Alendronate (Fosamax)

Reduces the incidence of Reduces the incidence of hip, wrist and vertebral hip, wrist and vertebral fractures in fractures in postmenopausal women (statistically significant) postmenopausal women (statistically significant)

Contraindications-Abnormalities of oesophagus, renal problems Contraindications-Abnormalities of oesophagus, renal problems Dose -10mg daily at least 30 mins before breakfast and sit Dose -10mg daily at least 30 mins before breakfast and sit

upright for at least 30 mins upright for at least 30 mins Disodium Etidronate (Didronel) Disodium Etidronate (Didronel)

Etidronate is effective in reducing Etidronate is effective in reducing vertebral vertebral fracture (statistically fracture (statistically significant). Dose- disodium etidronate 400mg once daily. significant). Dose- disodium etidronate 400mg once daily.


OESTROGEN RECEPTOR MODULATORS (Raloxifene) OESTROGEN RECEPTOR MODULATORS (Raloxifene) Work like oestrogen at bone without other harmful effects. Work like oestrogen at bone without other harmful effects. Can increase post menopausal symptoms so not to be given Can increase post menopausal symptoms so not to be given

within 5 years of menopause within 5 years of menopause CALCITONIN CALCITONIN Non sex, non steroid hormone Non sex, non steroid hormone Reduces resorption of bone Reduces resorption of bone Nasal form at dosages of 200 units per day Nasal form at dosages of 200 units per day Can be used for analgesia Can be used for analgesia CALCITRIOLCALCITRIOL (1,25 DIHYDROXYCHOLECALCIFEROL) (1,25 DIHYDROXYCHOLECALCIFEROL) The active metabolite of vit D. 0.25 microg o.d. The active metabolite of vit D. 0.25 microg o.d. may may reduce risk reduce risk

of vertebral #. Need monitoring of plasma calcium of vertebral #. Need monitoring of plasma calcium

RICKETS & RICKETS & OSTEOMALACIAOSTEOMALACIA

Def.: reduction in bone mineralization Def.: reduction in bone mineralization !!

OSTEOMALACIA,RICKETSOSTEOMALACIA,RICKETS

Normal bone metabolismNormal bone metabolism CALCIUM CALCIUM

99% in bone. 99% in bone. Main functions- muscle /nerve function, clotting. Main functions- muscle /nerve function, clotting. Plasma calcium- 50% free, 50% bound to albumin. Plasma calcium- 50% free, 50% bound to albumin.

Dietary needs- Dietary needs- Kids- 600mg/day, Kids- 600mg/day, Adolesc.-1300mg/day, Adolesc.-1300mg/day, Adult-750mg/day, Adult-750mg/day, Pregnancy-1500mg/day, Pregnancy-1500mg/day, Breastfeeding-2g/day, Breastfeeding-2g/day, Fractures- 1500mg/dayFractures- 1500mg/day

Absorbed in duodenum (active transport) and jejunum Absorbed in duodenum (active transport) and jejunum (diffusion), 98% reabsorbed in kidney prox. tubule, may be (diffusion), 98% reabsorbed in kidney prox. tubule, may be excreted in stool.excreted in stool.


Normal bone metabolismNormal bone metabolism

PHOSPHATE PHOSPHATE 85% in bone. 85% in bone. Functions-metabolite and buffer in enzyme systems.Functions-metabolite and buffer in enzyme systems.

Plasma phosphate mainly unbound. Plasma phosphate mainly unbound. Daily requ. 1-1.5g/dayDaily requ. 1-1.5g/day


Regulation of Calcium & Phosphate Metabolism:Regulation of Calcium & Phosphate Metabolism:Peak bone mass at 16-25 years.Peak bone mass at 16-25 years.Bone loss 0.3- 0.5% per year (2-3% per year after 6Bone loss 0.3- 0.5% per year (2-3% per year after 6 thth decade). decade).1.1. Parathyroid Hormone (PTH)Parathyroid Hormone (PTH)2.2. Vitamin D3Vitamin D33.3. CalcitoninCalcitonin4.4. Other Hormones: Other Hormones:

Estrogen: Prevents bone loss Estrogen: Prevents bone loss Corticosteroids: Increases bone loss Corticosteroids: Increases bone loss Thyroid hormones: Leads to Thyroid hormones: Leads to osteoporosis Growth osteoporosis Growth hormones: Cause positive calcium balance hormones: Cause positive calcium balance Growth factors Growth factors

RICKETS, OSTEOMALACIA RICKETS, OSTEOMALACIA

PATHOLOGY:PATHOLOGY: Sufficient osteoid, poor mineralization Sufficient osteoid, poor mineralization (Rickets is found only in children prior to the closure of the (Rickets is found only in children prior to the closure of the

growth plates, while growth plates, while OSTEOMALACIAOSTEOMALACIA occurs in persons of occurs in persons of any age. Any child with rickets also has osteomalacia, while any age. Any child with rickets also has osteomalacia, while the reverse is not necessarily true). the reverse is not necessarily true).


CAUSES:CAUSES:1.1. Nutritional deficiency Nutritional deficiency

1.1. Vit D Vit D 2.2. chelators of calcium- phytates, oxalates, phosphorous chelators of calcium- phytates, oxalates, phosphorous 3.3. Antacid abuse, causing reduced dietary phosphate binding Antacid abuse, causing reduced dietary phosphate binding

2.2. GI Absorption defects GI Absorption defects 1.1. Post gastrectomy Post gastrectomy 2.2. Biliary disease (reduced absorption of Vitamins ) Biliary disease (reduced absorption of Vitamins ) 3.3. Small bowel disease Small bowel disease 4.4. liver disease liver disease

3.3. Renal tubular defects Renal tubular defects 4.4. Renal osteodystrophy Renal osteodystrophy 5.5. Miscellaneous causes Miscellaneous causes


CLINICAL FEATURES:CLINICAL FEATURES: Rickets - Rickets -

TTetany , convulsions, failure to thrive, etany , convulsions, failure to thrive, restlessness, muscular flaccidity. restlessness, muscular flaccidity. Flattening of skull (craniotabes), Flattening of skull (craniotabes), Thickening of wrists from epiphyseal overgrowth, Thickening of wrists from epiphyseal overgrowth, Stunted growth, Stunted growth, Rickety rosary, spinal curvature, Rickety rosary, spinal curvature, Coxa vara, bowing, # of long bonesCoxa vara, bowing, # of long bones

Osteomalacia, - AOsteomalacia, - Aches and pains, muscle weakness loss of ches and pains, muscle weakness loss of height, stress #s.height, stress #s.


XRAY FINDINGS:XRAY FINDINGS:

RICKETS RICKETS Thickening and widening of Thickening and widening of physes, physes, Cupping of metaphysis, Cupping of metaphysis, Wide metaphysis, Wide metaphysis, Bowing of diaphysis, Bowing of diaphysis, Blurred trabeculae.Blurred trabeculae.

http://www.orthoteers.co.uk/Nrujp~ij33lm/Images7/rickets1.jpg


XRAY FINDINGS:XRAY FINDINGS:

OSTEOMALACIAOSTEOMALACIALoosers zones - incomplete Loosers zones - incomplete

stress # with healing lacking stress # with healing lacking calcium, on compression calcium, on compression side of long bones. side of long bones.

Codfish vertebrae due to Codfish vertebrae due to pressure of discs pressure of discs

Trefoil pelvis, due to Trefoil pelvis, due to indentation of acetabulae indentation of acetabulae stress #s stress #s

http://www.orthoteers.co.uk/Nrujp~ij33lm/Images7/osteomalacia1.jpg


INVESTIGATIONS:INVESTIGATIONS:

BLOOD TESTS BLOOD TESTS Calcium Reduced, Calcium Reduced, Phosphate reduced Phosphate reduced Alkalline Phosphatase increased Alkalline Phosphatase increased Urinary excretion of calcium diminished Urinary excretion of calcium diminished

Calcium phosphate products (= serum [Ca] x serum [PO4]) Calcium phosphate products (= serum [Ca] x serum [PO4]) normally 30. In rickets and osteomalacia is less than 24 normally 30. In rickets and osteomalacia is less than 24


MANAGEMENT:MANAGEMENT:

Depends on the causeDepends on the cause

Nutritional Nutritional Vitamin D deficiency Vitamin D deficiency Dietary chelators of calcium Dietary chelators of calcium

Phytates Phytates

Oxalates Oxalates Phosphorus deficiency (unusual) Phosphorus deficiency (unusual)

Antacid abuseAntacid abuse• Treatment- vitamin D (5000u) and Calcium (3g/day) Treatment- vitamin D (5000u) and Calcium (3g/day)


MANAGEMENT:MANAGEMENT:Depends on the causeDepends on the cause

Gastro-intestinal absorption defects Gastro-intestinal absorption defects Post-gastrectomy Post-gastrectomy Biliary disease Biliary disease Enteric absorption defects Enteric absorption defects

Short bowel syndrome Short bowel syndrome Rapid onset (gluten-sensitive enteropathy) Rapid onset (gluten-sensitive enteropathy)

Inflammatory bowel disease Inflammatory bowel disease Crohns Crohns CeliacCeliac


MANAGEMENT:MANAGEMENT:Depends on the causeDepends on the causeRenal tubular defects Renal tubular defects

Vitamin D dependant Vitamin D dependant type I type I type II type II Treatment; High levels of vit D Treatment; High levels of vit D

Vitamin D resistant (familial hypophosphatemic rickets) Vitamin D resistant (familial hypophosphatemic rickets) Treatment; Phosphate 1-3 gm daily, Vit D3 high doseTreatment; Phosphate 1-3 gm daily, Vit D3 high dose

Fanconi syndrome I, II, III Fanconi syndrome I, II, III Renal tubular acidosis Renal tubular acidosis


MANAGEMENT:MANAGEMENT:

Depends on the causeDepends on the cause

Renal Osteodystrophy – in chronic renal failureRenal Osteodystrophy – in chronic renal failure

Miscellaneous Miscellaneous Hypophosphatasia Hypophosphatasia Anticonvulsant therapyAnticonvulsant therapy

SURGERYSURGERY

For deformitiesFor deformities

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Osteo osteomalacia ricket2