1. Metabolic bone diseasesBy
Dr. Abdelaty Shawky Dr. Gehan Abdel-Monem

2. Bones…. What do they need to be strong?
Calcium/ PO4
Vit D
PTH
calcitonin

3. Sources of Vitamin D and importance

4. * VIT D LEVEL IN SERUM: 25 (OH) D3 level ng/ml DEFICIENT < 10
INSUFFICIENT
OPTIMAL
HIGH
TOXIC
>90

5. Vitamin D Deficiency in Saudi Arabia
Group mostly affected are:
Breast- Fed infants because Human milk contains little vitamin D,
Age < 2 years
Darked –skin children because darkly pigmented skin, which blocks penetration of ultraviolet light necessary for formation of cholecalciferol (Vit. D3) from cholesterol in the skin.
Low socio-economic Class
Urban > Rural

6. PARATHYROID HORMONE
Stimulus for its secretion : fall in serum Ca.
PTH promotes bone resorption process and is adversely affected by calcitonin.
PTH also stimulates the excretion of phosphates by the kidneys; this inhibition of phosphate resorption in turn enables calcium resorption.
In GIT - indirectly increases calcium absorption by increasing the synthesis of active vit D 3 by stimulating alpha hydroxylase

7. CALCITONIN It is produced by para follicular c cells of thyroid.
It is a calcium lowering hormone in serum by inhibiting bone resorption by decreasing the no & activity of osteoclasts .
So calcitonin acts counter to PTH. Calcitonin inhibits bone resorption thus causing serum calcium levels to fall.

8. Metabolic bone Diseases

9. Rickets
Osteomalacia
osteoporosis

10. Rickets: Osteomalacia:
Disease of growing bones of children(epiphyseal plate not closed )in which defective mineralization occurs in both bone and cartilage of epiphyseal growth plate.
Osteomalacia:
Disorder of mature bones in adult (after epiphyseal plate closure )in which mineralization of new osteoid bone is inadequate or delayed

11. Nutritional deficiency:
* Causes of rickets:
Nutritional deficiency:
- Excess of phytate in diet which form insoluble compounds with calcium so prevent its absorption (chapati flour)
2. Malabsorption: as in Celiac disease, Pancreatic insufficiency
3. Hepato-biliary diseases:
Biliary Atresia
Cirrhosis
neonatal hepatitis

12. 4. Drugs:
Anti-convulsants.
Phenobartbitone.
Phenytoin
5. Renal causes :
-Renal osteodystrophy
- Renal tubular acidosis.

13. * Types of Rickets:
(1). Vitamin D deficient rickets: there is decrease in vitamin D inside body.
(2). Vitamin D dependent rickets: there is defect in the process of vitamin D activation.
(3). Vit D resistant rickets: either
-Hypophosphatemic rickets.
- End organ resistance to 1,25 Dihydroxy Vit D3.

14. Vitamin D deficient rickets
The predominant cause of rickets is a deficiency in vitamin D, which is required for normal calcium absorption from the gut.
Malabsorption leads to low levels of calcium in the blood. This not only prevents proper bone growth, but can also lead to calcium being released form the bones to increase its blood level.

15. Hypophosphatemic rickets
Nutritional phosphate deficiency.
Prematurity.
Decreased intestinal absorption of phosphate
Ingestion of phosphate binders (aluminum hydroxide).
Renal phosphate wasting.

16. Diagnosis of rickets
A. Clinical features of rickets: (1). Skeletal manifestations (2). Extraskeletal manifestations B. Investigations.

17. (1). Skeletal manifestations
Craniotabes: The earliest sign of rickets in infant, is (abnormal softness of skull)
Delayed closure of anterior fontanel.
Frontal and parietal bossing: Rounded prominence of the frontal and parietal bones in an infant’s cranial vault
Delayed eruption of primary teeth.
Enamel defects and caries teeth.
Rachitic rosary
Swelling of the costo-chondral junctions.

18. Harrison’s groove:
Lateral indentation of the chest wall at the site of attachment of diaphragm because the patients lack the mineralized calcium in their bones necessary to harden them; thus the diaphragm, which is always in tension, pulls the softened bone inward.
Enlargement of long bones around wrists and ankles
Bow legs
knock knees
Green stick fractures
Deformities of spine, pelvis and leg – rachitic dwarfism
Growth retardation due to impaired calcification of bone epiphysis.

19. Frontal and parietal bossing

20. Rachitic Rosary beads due to Swelling of the costo-chondral junctions

21. Rachitic Rosary beads due to Swelling of the costo-chondral junctions

22. Costochondral junction

23. Harrison’s groove Lateral indentation of the chest wall at the site of attachment of diaphragm

24. Wrist enlargement

30. Wide ankle

31. (2). Extra – skeletal manifestations:
SEIZURES.
TETANY i.e periodic painful muscular spasms and tremors, caused by faulty calcium metabolism and associated with diminished function of the parathyroid glands.
HYPOTONIA AND DELAYED MOTOR DEVELOPMENT Muscle weakness
PROTUBERANT ABDOMEN, BONE PAIN, WADDLING GAIT AND FATIGUE.
In older children presenting with rickets

32. Clinical manifestations in rickets

33. B. Investigations * BASIC INVESTIGATIONS TO CONFIRM RICKETS:
Serum Ca, P: Hypocalcemia if Serum Calcium less than 8.0 mg/dl
X rays of ends of long bones at knees or wrists:
Widening and cupping of the distal ends of shaft.

35. Osteoporosis & Osteomalacia

36. Difference Between Osteoporosis & Osteomalacia
Osteoporosis refers to the degeneration of already constructed bone, making them brittle, while osteomalacia is an abnormality in the building process of bone, making them soft.

37. Osteoporosis
The word osteoporosis literally means porous bones . It occurs when rate of degeneration of already constructed bone is rapid and exceed rate of bone building .
This leads to loss of an excessive amount of their protein and mineral content .
An osteoporotic bone characterized by:
Thinning of bone trabecula
low bone mass and volume.
Leading to enhanced bone fragility and increase in fracture risk even with any trivial trauma.

38. Osteoporotic Vertebra

40. WHO Guidelines for Determining Osteoporosis
We diagnose Osteoporosis if patient bone density is below the average of the same age and sex.
Osteoporosis is defined as -2.5 or lower, meaning a bone density that is two and a half standard deviations below the mean of a thirty year old man/woman.

42. * Factors which decrease risk of osteoporosis in men:
1. Men have about 5 percent higher bone density after their growing period than women. 2. Men also tend to have bigger bones, and it's generally harder to break bigger bones. 3. men often have larger muscles than women and may be less likely to fall so not liable for fracture.

43. * Types of osteoporosis:
Idiopathic type:
- which is subclassified into
Post menopause (Type I).
Senile type (Type II).
B. Secondary type : which occur secondary to any other disease, or drug intake.

44. Idiopathic Osteoporosis:
Postmenopausal osteoporosis (type I)
Caused by lack of estrogen.
Estrogen loss triggers increases in InterLeukin-1, IL-6, and Tumor Necrosis factor lead to increased osteoclast development and lifespan.
Also estrogen loss stimulate parathormone hormone.
Senile osteoporosis (type II): as a result of aging

45. Normal vs. Osteoporotic Bone

46. Commonest sites affected by osteoporosis

47. Osteoporosis in vertebra

51. Investigations:
To diagnose degenerative bone diseases as osteoporosis:
The primary method of testing is DEXA or dual energy X-ray absorptiometry ,This can detect the density of your bones in the most susceptible areas.
Sometimes, ultrasound or CT scans are also used to make a diagnosis.

52. * Prevention of osteoporosis:
Good healthy diet: containing calcium and vitamin D specially during period of bone growth.
Physical activity: Both of them help to reach the optimal bone density during adulthood. So form strong and dense bone so become not easy to be affected by any degenerative changes.