Introduction
Osteomalacia is the bony manifestation of altered vitamin D, calcium, and phosphorus metabolism in an adult.1 Vitamin D deficiency accounts for the most common nutritional deficiency among children and adults. 2 Osteomalacia describes a disorder of “bone softening” in adults that is usually due to prolonged deficiency of vitamin D.3 This results in abnormal osteoid mineralization.4 There are multiple causes of osteomalacia, but, regardless of the cause of the abnormal metabolism, adults have similar long bone and trunk deformities.5 Osteomalacia is a metabolic bone disease characterized by impaired mineralization of bone matrix.6 Bone creation occurs by the deposition of hydroxyapatite crystals on the osteoid matrix.7 Most common casues of this disease include: decreased Vitamin D production, decreased Vitamin D absorption, altered Vitamin D metabolism, hypophosphatemia, hypocalcemia and medications.8 Because vitamin D deficiency has become less common in the United States, osteomalacia is not often considered as differential diagnoses in patients who have extremity pain or deformity, however, in developing countries such as India, Vitamin D deficiency is a major concern as majority of the population has moderate to severe deficiencies of Vitamin D.9 In processes that decrease the amount of vitamin D or its bioproducts, normal serum calcium will be maintained by mobilizing calcium from the bones.10 Specifically, PTH will be secreted by the parathyroid glands in response to hypocalcemia from vitamin D deficiency and will attempt to bring the body back to normal serum calcium levels. 11 Bones are the primary target to recruit calcium, and by extracting calcium from the bones, osteomalacia will ensue.
Therefore, adults with processes that disrupt vitamin D metabolism and its production are at risk for eventually developing osteomalacia and its clinical manifestationsWhen treating patients with osteomalacia, the orthopaedist always must be concerned about the effect treatment may have on impaired calcium homeostasis.12 Before surgery, management of the metabolic defect with vitamin D, phosphorus, and calcium or other appropriate measures should be done for several months. If the disease is not controlled metabolically, the deformity is likely to recur after corrective osteotomy. 13
Case Report
The patient was informed that her case would be published in a medical journal and informed consent was taken from her.
History
The patient is a 21-year old girl with complains of pain in right hip following a self-fall while playing two weeks ago. The pain was sudden in onset, gradually progressive in nature, only mildly relieved on medications, with no diurnal variation. She had no associated fever, myalgia, generalized malaise or paresthesias.
The patient presented to our orthopaedic OPD after seeing multiple doctors and was diagnosed as a Closed Fracture Neck of Femur Right and was advised admission and surgery for the same. Her parents, however, wanted another opinion before going for surgery and hence, came to us.
Past history
The Patient has no other known systemic diseases and has no history of significant illnessesin the past.
Personal history
The patient is conscious and oriented to time, place and person.She is a college-going student pursuing her graduation. She is thinly built and averagely nourished. She is a vegetarian, does not smoke or consume alcohol, is not into sports and spends most of her time in the college or home. She is not active sexually and does not have any gynaecological complains. Her bowel and bladder movements are normal and her sleep schedule is adequate.
Medication history
The patient is not currently on any medications except for NSAIDs since the past 2 weeks for her pain. She has no history of significant medications previously.
Menstrual history
The patient is on Day 14 of her current cycle, her cycles are regular and of 28-29 days with no significant complains.
Examination
Straight leg raising test: Passive - Bilateral 90 degrees and not painful.
Straight leg raising test: Active - Left 90 degrees not painful, Right 90 degrees with mild pain.
Pelvic compression test: Mild pain.
Dorsalis pedis artery: Bilateral palpable and equal.
Posterior tibial artery: Bilateral palpable and equal.
Local examination: No local rise of temperature, mild to moderate tenderness elicited on anterior aspect of hip. No obvious swelling or deformity seen.
Investigations: A plain X-ray was done initially.
X-rays were initially suggestive of a fracture, so NCCT pelvis was done. A NCCT lumbo sacral spine was also done to rule out spine injuries.
X-rays and CT along with the clinical history and examination were not suggestive towards a fracture.
Hence, metabolic workup was done for the patient.
Metabolic workup along with radiographic investigations confirmed that this patient was a case of Osteomalacia and the X-rays were actually suggestive of metaphyseal “Looser’s Zones”. Decreased Vitamin D, decreased calcium and normal to increased ALP were all confirmative of the diagnosis of osteomalacia.
Treatment
The patient was restriced weight bearing for initial 4 weeks and then started on partial weight bearing for another 2 weeks. Patient was treated with Tab Methylcobalamin 1500 ug OD, Tab Calcium 500 mg OD, Vitamin D 60,000 Units PO once a week, Tab Paracetamol 500 mg SOS and Tab Pantoprazole 40 mg OD.
Patient was instructed to take diet accordingly and follow ups were done at 1, 2, 4, and 6 weeks.
Results
At 6 weeks, patient had no complains of pain in the hip joint and no limping. X-rays done showed complete radiographic healing of the looser zones.
Discussion
Osteomalacia is a metabolic bone disorder which is very prevalent in a developing country like India and is often overlooked and underdiagnosed by many orthopedicians. Reasons are varied, the vagueness of symptoms, the loss to follow up in many patients, the lack of proper education and knowledge both among the doctors and the general masses altogether provide a gross problem of mismanagement of this disease. Many surgeons would have thought of this as a neck of femur fracture and operated on the patient and would have had substandard results with no patient satisfaction whatsoever. Having a diagnosis of Osteomalacia in mind, especially in the female population, can lead to correction of such potentially hazardous misdiagnosis. The patient eventually needed just medical managament and healing was visible within 6 weeks. As a healthcare provider, it is our duty to make sure to keep such underdiagnosed conditions on the back of our mind to be able to make such diagnosis and be able to treat patients correctly. Simple supplementation with Vitamin D and Calcium can provide miraculous results in such patients with low cost and no surgeries and hence should always be diagnosed correctly and treatment started on time.
Conclusion
Our case report aims to conclude that one should not jump to fracture treatment just by looking at the radiograph and should instead find the etiology first. Such cases are often misdiagnosed and operated upon, leading to significant distress, physically, emotionally and financially to patients. Proper knowledge of differentials and simple pharmacological treatment can give miraculous results and save unwanted surgeries in such patients with osteomalacia.
