1. Adult Medical-Surgical Nursing Musculo-skeletal Module: Osteomalacia

2. Bone Formation  Bone is a dynamic tissue constantly reforming and resorbing  Bone cells (osteocytes) are:  Osteoblasts (bone formation)  Osteoclasts (bone destruction, resorption, remolding)

3. Bone Formation  Osteoblasts secrete collagen and glycoproteins to form a bone matrix  Deposit minerals in the matrix (calcium, magnesium, phosphorus, chloride)  Osteoclasts resorb calcium and minerals from bone causing depletion

4. Hormones Affecting Bone Turnover  Hormones which promote bone formation: (inhibit resorption)  Oestrogen and calcitonin  Testosterone in males ( ↓ with age)  Hormone which increases bone turnover and resorption:  Parathormone ( ↑ with age)  (Also insufficient oestrogen/ calcitonin/ testosterone)

5. Factors Influencing Bone Formation  Local stress: usage/ weight-bearing and walking aid bone formation  (Immobility leads to increased calcium resorption from bone and osteoporosis)  Adequate calcium and vitamin D (intestinal absorption of calcium)  Parathormone/ Calcitonin activity  Blood supply (inadequate → necrosis)

6.  Bone Pathology

7. Bone Pathology: Classification  Osteoporosis  Osteomalacia  Pagets Disease  Bone tumour:  Benign  Malignant primary  Metastases

8. Osteomalacia: Description  A metabolic bone disease  Reduced mineralisation of bone leading to:  Softening and weakening of bones  Skeletal deformities and pathological fractures

9. Osteomalacia: Aetiology  Deficient activated vitamin D (calcitriol) leading to reduced absorption of calcium from the intestine, and reduced calcification and ossification of bones

10. Osteomalacia: Pre-disposing Risk Factors  Malabsorption syndrome: Inflammatory bowel disease/ intestinal resection/ biliary obstruction(vitamin D is fat-soluble)  Renal disease: Poor activation vitamin D for calcium/phosphate absorption; calcium used to combat acidosis in renal failure  Hyperparathyroidism  ↓ Exposure to sunlight; malnutrition (childhood Rickets)

11. Osteomalacia: Pathophysiology  Reduced activated vitamin D →  Reduced intestinal absorption of calcium and excessive loss of calcium from the body  Low serum calcium and phosphate  Demineralisation of bone (calcium resorption) with softening, weakening, deformity, fracture  Muscle weakness

12. Osteomalacia: Clinical Manifestations  Bone pain and tenderness to touch  Skeletal deformity (bowed legs, kyphosis)  Waddling gait, limping  Pathological fractures  Vertebral compression  Muscle weakness  Unsteadiness, risk of falls and fracture

13. Osteomalacia: Diagnosis  Patient history and symptoms  Xray: indicates demineralisation, fractures  Low serum calcium and phosphate  Raised serum alkaline phosphatase  Urinary calcium and creatinine low  Bone biopsy (shows increase of osteoid “pre-bone”: faulty growth)

14. Osteomalacia: Medical Management  Treat underlying cause if possible  Sunlight  Mineral supplements (calcium/ vitamin D)(avoid overdose: monitor serum calcium)  ↑ dietary protein, calcium, vitamin D  Gentle handling, pain relief  Support (brace) or corrective surgery for deformity

15. Osteomalacia: Nursing Considerations  Ensure patient education about condition and means of preventing deterioration:  Adequate dietary and calcium/ vitamin D supplements (note levels)  Adequate sunlight  Psychological/ emotional support  Careful gentle handling and ensure adequate pain relief