1、Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,病例报告,Case Report,病史,History,A 32-year-old India woman,Right hip pain 4 month,left hip pain 10 days,Lower limb weakness and difficulty to,stand up,from sitting,Waddling Gait.ROM of left Hip was limited,No trauma history,PMH unremarkable,MRI,Right,第一次就诊,2013-10,月,Right,Diagnosis,诊断,DDH,Osteoarthritis,Infection or Tuberculosis,Fracture,Ankylosis spondylitis,Rheumatoid arthritis,Bo
2、ne marrow edema（femur head necrosis）,Lab Tests化验,CBC:,wbc 13000/,ESR,：,20mm/H,RF:normal,ASO,：,normal,Uric acid,：,normal,CRP:normal,Treatment,治疗,NSAIDs,Antibiotic,Much Much Better,第二次就诊,2014-5,Asking neurological expert consult.,Right hip pain increased in ten days.,Difficulty to stand up from sitting.,Waddling Gait.,Lower extremity muscle MRC scale:M4,X-Ray,Right,Fracture,Diagnosis,Fracture,Atypical fracture,Pathological fracture,Stress fracture,Pseudo-fracture,1year,alendronate,2009.7,2010.3,20
3、10.5,2012.3,What,is,different between two case?,Diagnosis诊断,Reasons for,“,Fractures,”,?,Reasons for Muscle weakness?,BMD,骨密度,股骨颈,-3.5,Wards,三角,-3.2,Lab Tests,CBC:normal,ESR:,30mm/h,RF:Negtive,Uric acid:normal,CRP:,28.2mg/L,T3T4:normal,ACA&AKA:normal,HLA-B27:normal,ASO:normal,Lab Tests,PTH:,145ng/L(15-65),Ca:2.4,P:0.54mmpl/L(0.8-1.6),Alkaline phosphatase:,305mmol/L(35-135),25-hydroxy Vitamin D:,75),Vitamin D Deficiency,维生素,D,缺乏,Common Causes 原因,Inadequate intake,Decreased exposure to sunlight,Gas
4、tric bypass,Drug,Risk facters,Vegetarian,(no egg&milk),India people immigrate to high latitude area,Dark skin,高危人群,Vitamin D/symptoms,Vidamin,D,Valley valley impordand do musclosgelendon,Bone pain(Hydration of bone matrix),Muscle weakness,Difficulty in walking,TB infection(50mmol/L),Myopathy病理,Osteomalacia can present first as severe muscle weakness and difficulty walking 13%.,Bone turn over about 5%/year,patients may develop myopathy insidious to over years.,Ca+is critically important for muscl
5、e contractility,Skeletal muscle contain 1-25 vitamin D receptors that,Diagnosis,Again,Fracture,Atypical fracture,Pathological fracture,Stress fracture,Pseudo-fracture,讨论,Osteoporosis,骨质疏松,Osteomalacia,骨质,软化,Osteoporosis骨质疏松,WHO BMD -2.5T,In osteoporosis,the bones are porous and brittle.,硬-量小,Osteomalacia骨软化,The softening of the bones due to,defective bone mineralization,（骨量大,软）,;T score 3,Vitamin D deficiency,Renal tubular acidosis,Tumor-induced osteomalacia FGF-23,Chronic renal failure,Genetic
6、disease,Pathology,DDx,Atypical fracture,Pseudo-fracture,Atypical Fracture,Atypical Fracture,Pseudo-fracture,Atypical Fracture,Severe suppression of bone turnover,Leads to the accumulation of bone microdamage and the development of an insufficiency fracture at the point of maximal,Weight-bearing stress,namely at the subtrochanteric or diaphyseal femur,Looser Pseudo-fracture,These lesions are composed of poorly mineralized osteoid matrix and are,NOT true fractures,or stress fractures.,Occur on the
7、 concave side(compressive aspect).,Osteomalacia骨软化,Osteomalacia,Reddy Munagala VV,Tomar V.N Engl J Med 2014;370:e10.,Different,Micro damage,Stress fracture,微骨折累积的疲劳骨折,Bone soften,Pseudo-fracture,骨软化造成假骨折,最终诊断,Vitamin,D,deficiency,Osteomalacia with bilateral proximal femoral pseudo-fractures(Looser-Milkman syndrome),Proximal myopathy,NEXT,Tetracycline labeled bone biopsy,Rule out Kidney disease,Bone scan,Simple Test,25-Vitamin D half life 15Days,1-25 Vitamin D half life 15h.,总结,Tips,成年人的维生素,D,缺乏并非罕见，容易被忽视,2case/May,。,维生素,D,缺乏不仅可以最终导致骨的软化，而且早期造成近躯干肌肉无力，容易误诊。,骨质疏松和骨软化具有不同病理基础。,骨软化多发生在骨的压力侧。,不典型应力骨折发生在骨的张力侧。,
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