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Child abuse or osteogenesis imperfecta: how can we tell?

Osteogenesis imperfecta may be difficult to differentiate from nonaccidental trauma. Social history may prejudice the physician in favor of or against considering the diagnosis of child abuse. Three cases of osteogenesis imperfecta that were initially diagnosed as nonaccidental trauma are presented. The availability of biochemical analysis of type I collagen was instrumental in confirming the diagnosis of osteogenesis imperfecta in all three cases.

Child↗

[Case report of osteogenesis imperfecta].

Osteogenesis imperfecta (OGI) is a rare genetic disease which, as a result of a disorder in the formation of the organic stroma of the bone due to a defect in osteogenic function, induces brittle bones, whereby only weak forces bring about multiple, repeated pathological fractures. This disease is thought to entail various problems with regards to carrying out pediatric dentistry due to the ease with which bones may be fractured. We report here the findings obtained as a result of the careful examination of a 1-year-3-month-old girl encountered in our practice and who was diagnosed as having osteogenesis imperfecta. 1) Out of the three major symptoms for osteogenesis imperfecta, this case showed signs of fragile bones and blue scleras, but did not reveal signs of deafness. 2) There was retardation in system growth and development. 3) Aside from a high level of alkaline phosphatase, there were no notable abnormalities revealed in the biochemical blood tests. 4) Dentinogenesis imperfecta was observed throughout the erupted teeth. 5) There was a definite improvement in cooperation with each visit to the clinic.

Dental Care for Persons with Disabilities↗

Osteogenesis imperfecta.

Osteogenesis imperfecta describes a group of heritable disorders characterized by excessive bony fragility and reduced skeletal mass. It is classified in terms of its clinical manifestations, but our understanding of the underlying genetic defects in collagen synthesis is increasing rapidly. The nonoperative and surgical orthopedic approaches to osteogenesis imperfecta aim at the maximum preservation of limb strength and the correction of deformities. Various pharmacologic agents have been administered to patients with osteogenesis imperfecta, but to date, none have proved effective in controlled trials. Prenatal diagnosis has been attempted and seems certain to assume greater importance as knowledge of the molecular genetic basis of the disease increases.

Child↗

Experimental study of free periosteal autograft. II. Increasing osteogenesis of periosteum.

The difference in osteogenesis of the periosteal graft and the effects of changing the recipient environment were studied in 26 young and 16 adult rabbits. The periosteal grafts from bilateral tibiae were implanted to the right and left sides of the abdominal wall, on the right side a coagulum was added. For quantitative examination, radionuclide, CT, ion-selective electrode, atomic absorption spectrometry and biochemical autoassay methods were used. The results showed that osteogenesis of periosteal grafts may increase by changing the local environments. The amount of periosteal bone formed in the adult rabbits was obviously less than in the young. The bone formation of the periosteal grafts with a coagulum, especially in the adults was increased. The possible mechanism of increasing periosteal osteogenesis by the coagulum is discussed.

Animals↗

Osteogenesis imperfecta type IV. Detection of a point mutation in one alpha 1(I) collagen allele (COL1A1) by RNA/RNA hybrid analysis.

We have identified a point mutation in one alpha 1(I) collagen allele (COL1A1) of a child with the type IV osteogenesis imperfecta phenotype. When compared to parental and control samples, skin fibroblasts of the proband synthesized two populations of type I collagen molecules. One population was normal; the other was delayed in secretion and electrophoretic migration due to post-translational overmodification. Two-dimensional gel electrophoresis of the CNBr peptides demonstrated a gradient of overmodification beginning near the carboxyl-terminal CB peptides. This predicts that the mutation delaying helix formation is near the carboxyl-terminal end of one of the component chains of type I collagen. The mRNA of the patient was probed with overlapping antisense riboprobes to type I collagen cDNA. Cleavage of a mismatch in RNA/RNA hybrids of RNase A allowed the location of the mutation to a 225-base pair region of alpha 1(I) cDNA. The mismatch was not present in RNA/RNA hybrids from either parent. This region of both alpha 1(I) alleles of the patient was isolated by screening a lambda ZAP cDNA library. Sequence determination of both alleles demonstrated a single nucleotide change, G----A, resulting in the substitution of a serine for a glycine at amino acid residue 832. This point mutation occurs in the coding region for alpha 1(I) CB6 and is concordant with the protein data. The finding of a glycine substitution in an alpha 1(I) chain of a patient with the milder type IV osteogenesis imperfecta phenotype requires modification of current molecular models for types II and IV osteogenesis imperfecta.

Alleles↗

The histology of distraction osteogenesis using different external fixators.

The local biology of distraction osteogenesis using Ilizarov and Wagner external fixators was compared in unilateral tibial lengthenings in two groups of eight dogs. Serial roentgenograms with histological correlation revealed some basic similarities as well as distinct differences between the two groups. All dogs fully bridged the experimental gap by intramembranous ossification. Subtle histological changes in the alignment of collagen bundles and subsequent ossification reflected the mechanical configuration of each fixator. The multiplanar, full-pin Ilizarov system delivered concentric load to the site of osteogenesis, inducing perfectly parallel columns of new bone. The uniplanar, one-half pin Wagner system induced angulation of the collagen and subsequent bone columns on the basis of eccentric load to the osteogenic interface. Despite a significant difference in axial rigidity, the Ilizarov and Wagner external fixators induced osteogenesis of equal volume.

Animals↗

Altered triple helical structure of type I procollagen in lethal perinatal osteogenesis imperfecta.

Cultured dermal fibroblasts from an infant with the lethal perinatal form of osteogenesis imperfecta (type II) synthesize normal and abnormal forms of type I procollagen. The abnormal type I procollagen molecules are excessively modified during their intracellular stay, have a lower than normal melting transition temperature, are secreted at a reduced rate, and form abnormally thin collagen fibrils in the extracellular matrix in vitro. Overmodification of the abnormal type I procollagen molecules was limited to the NH2-terminal three-fourths of the triple helical domain. Two-dimensional mapping of modified and unmodified alpha chains of type I collagen demonstrated neither charge alterations nor large insertions or deletions in the region of alpha 1(I) and alpha 2(I) in which overmodification begins. Both the structure and function of type I procollagen synthesized by cells from the parents of this infant were normal. The simplest interpretation of the results of this study is that the osteogenesis imperfecta phenotype arose from a new dominant mutation in one of the genes encoding the chains of type I procollagen. Given the requirement for glycine in every third position of the triple helical domain, the mutation may represent a single amino acid substitution for a glycine residue. These findings demonstrate further heterogeneity in the biochemical basis of osteogenesis imperfecta type II and suggest that the nature and location of mutations in type I procollagen may determine phenotypic variation.

Cyanogen Bromide↗

Defective association between collagen fibrils and proteoglycans in fragile bone of osteogenesis imperfecta.

The relationship between collagen fibrils and proteoglycans in the bone matrices of three osteogenesis imperfecta (OI) patients was observed ultrastructurally to clarify the mechanism responsible for pronounced bony fragility. Collagen fibrils and noncollagenous components were prepared from the bone matrix of patients with osteogenesis imperfecta and a control sample, respectively. Compared with the control, a 95.2% decrease was found in the number of proteoglycan granules periodically associated with the cross-banding of collagen fibrils in one OI sample from a patient with severe bony fragility. Extractability of collagen fibrils and proteoglycans was high in this sample. However, proteoglycans and collagen fibrils could be reattached in vitro to reproduce the condition observed in the controls. There was no decrease in the number of proteoglycan granules attached to prepared collagen fibrils in a sample from a patient with predominantly bowing deformity of bones. Hypothetically, the separation of proteoglycans from collagen fibrils in OI may be associated with increased bony fragility. In osteogenesis imperfecta patients, the mechanism inducing bowing deformity appears to be different from that inducing fragility.

Bone and Bones↗

Mechanical induction of Osteogenesis. Preliminary studies.

The animal model developed in the Soviet Union by Ilizarov has been reliably reproduced by us for the mechanical induction of osteogenesis using slow distraction. Our preliminary studies in six adult dogs indicate that this osteogenesis originates from well-structured intramembranous ossification, with rapid maturation to lamellar bone, indistinguishable from surrounding host bone. Mineralization increases steadily, reaching critical levels for radiographic visualization between Days 21 and 28. In this model, the osteogenic area then exceeds normal bone density temporarily but returns to normal density within three months. Distraction for 28 consecutive days (at 0.25 millimeters every six hours using rigid transfixion wires, as Ilizarov describes) reliably lengthened the tibiae by 12 percent, increasing mass by 27 percent, and volume by 26 percent with only a one percent change in overall density. The process required four months to add 24 millimeters of mature, lamellar bone capable of full weight-bearing by the dogs. This rate of osteogenesis, estimated at 202 microns per day, is four times faster than a human's fastest growth plate (child's distal femur at 50 microns per day). Calcium/collagen ratios did not differ significantly from normal bone controls.

Animals↗

Congenital pseudarthrosis of the tibia associated with cleidocranial dysostosis and osteogenesis imperfecta. A case report.

A neonatal boy with cleidocranial dysostosis presented with congenital pseudarthrosis of the tibia. Clinical observation later revealed he also had osteogenesis imperfecta. The osteogenesis imperfecta was classified as Type I and the congenital tibial pseudarthrosis as Type II. Cleidocranial dysostosis, osteogenesis imperfecta, and congenital pseudarthrosis of the tibia have not been previously reported to coexist in one individual.

Abnormalities, Multiple↗

Psychosocial aspects of osteogenesis imperfecta.

Osteogenesis imperfecta is a heterogeneous group of inherited disorders characterized by bone fragility and recurrent fractures. It is currently classified into four types on clinical grounds and appears to arise from different disorders of bone collagen synthesis. The biochemical identification of disturbances in collagen metabolism and the genetic delineation of new mutations of collagen genes have made prenatal diagnosis by molecular methods feasible in some cases. Most people with osteogenesis imperfecta suffer frequent fractures (and sometimes consequent serious disability), for which there are few effective preventive measures. This disorder may have a profound psychosocial influence on patients and their families. In this report the extent of this influence is reviewed and aspects important to the medical community are highlighted; these include the emotional burdens imposed by unfounded suspicions of child abuse, the social and financial costs of repeated hospitalization and immobility, and the frustrations generated by the lack of helpful, practical information for families and health care workers. An important social outcome has been the rise of self-help organizations, exemplified by the Canadian Osteogenesis Imperfecta Society. For Canadian families the society has been an important vehicle for exchange of information and an active, positive response to a lifelong, often severely disabling disorder.

Canada↗

The development of the spinal deformities in osteogenesis imperfecta.

Evaluations were made of the spinal deformities in 22 of 30 patients (osteogenesis imperfecta congenita, eight; osteogenesis imperfecta tarda I, 13; osteogenesis imperfecta tarda II, one) treated at Hamagumi Gakuen Children's Hospital from 1959 to 1980. Seven of the congenital type patients were in the severe curve group (greater than 50 degrees), four of whom showed more than 100 degrees of curvature. The spinal deformities in the congenital type progressed rapidly after five years of age and reached a maximum around 12 years of age. The scoliosis in the tarda type patients developed slowly, but then progressed rapidly after the curve exceeded 50 degrees. The complications of the spinal deformities included disability on ambulation, inactivity in daily living, and possibly respiratory dysfunction. Progression of the spinal curvature should be prevented by functional bracing or surgical treatment before severe complications arise.

Adolescent↗

Donor cells' contribution to osteogenesis in experimental cancellous bone grafts.

Osteogenesis in subcutaneous, cancellous bone isografts in the rat was assessed at 16 days from the uptake of 85Sr. by comparing the uptake in grafts devoid of one or more cellular components, the contribution of each to osteogenesis was estimated. The per cent contribution of each of the osteogenetic elements was: endosteal lining cells together with marrow stroma, 60%; periosteal cells, 30%; free, hemopoietic marrow cells and osteocytes, no significant contribution. These findings are compared with those previously reported for cortical bone isografts and it appears that the rate of osteogenesis is 2.2 times higher in cancellous grafts than in cortical grafts of the same weight, but only 1.7 times higher when grafts of the same volume are compared. Osteogenetic and hemopoietic activities associated with marrow appear to arise from different groups of cells. It is shown how, with iliac bone marrow, these two groups of cells may be separated physically, the hemopoietic cells being removed by means of a jet of saline, and the osteogenetic cells by subsequent enzyme treatment plus a second jet of saline. The osteogenetic and hemopoietic elements were difficult to separate from bone marrow within the femoral diaphysis.

Animals↗

[Valve replacement for mitral in incompetence in a patient with osteogenesis imperfecta (author's transl)].

Reports on aortic and mitral valve alterations in patients with osteogenesis imperfecta, a congenital connective tissue disorder, are sparse in the literature. Aortic valve incompetence is more common than mitral valve dysfunction. Though the clinico-pathological and histological features of valve alterations are very similar to those seen in Marfan's Syndrome, valve dysfunctions in osteogenesis imperfecta are rarer than in Marfan's Syndrome. In a 23-year-old patient with typical clinical feature of osteogenesis imperfecta, mitral incompetence was detected by echo- and angiography. Patient was provided with a St.-Jude-Medica prosthesis and postoperative course was without any complications.

Adult↗

Aftermath of osteogenesis imperfecta: the disease in adulthood.

To determine the effects of osteogenesis imperfecta and its treatment on adult life, thirty-one patients with osteogenesis imperfecta were examined at an average of nineteen years postoperatively. Seventy-two per cent of the operations that had been performed on these patients in childhood consisted of multiple osteotomies with intramedullary fixation to reduce fracture frequency and prevent bowing of the lower limbs. Only eight patients had remained non-ambulatory, seven of whom had severe long-bone deformity. Based on the study of these patients, we suggest that the severity of diaphyseal tapering and of disease are related; that scoliosis is frequent in adults with osteogenesis imperfecta; that the improvement gained at operation is maintained and enhances ambulation; and that as adults, these patients are generally very productive and socially adaptable individuals.

Adolescent↗

Evaluation of distraction osteogenesis by scanning electron microscopy.

A model of bifocal distraction osteogenesis in the canine model was used to assess and quantitate the mineral content of the newly forming bone within the canine mandible. A 2-cm defect was created in the body of the mandible, and after a posterior osteotomy, the transport disk was advanced at 0.25 mm per 8 hours for 21 days and then held in rigid fixation for an additional week. As a control for this study, three additional dogs underwent the same procedure with the exception that the transport disk was not advanced. Electron dispersive spectroscopy analysis was performed on the newly formed regenerate bone and compared with areas of existing cortical bone of both the transport disk and the mandible. In the control model, special note was made of the pericortical callus at the osteotomy site as well as of the regenerative bone that filled the 2-cm defect in the body of the mandible. Calcium/phosphorous ratios were used to assess the composition of the mineralized regions of the mandible. The regenerate bone that filled the defect and the mineralized callus surrounding the site of osteoclasis in the control mandible were significantly different in composition when compared with the regenerate bone that formed during distraction osteogenesis. This suggests that distraction osteogenesis may effect an initial matrix production that is more similar in composition to the mature cortical bone from which it was derived than does periosteal regeneration and filling of an osseous defect.

Animals↗

Substitution of serine for glycine 883 in the triple helix of the pro alpha 1 (I) chain of type I procollagen produces osteogenesis imperfecta type IV and introduces a structural change in the triple helix that does not alter cleavage of the molecule by procollagen N-proteinase.

Type I procollagen secreted by dermal fibroblasts from an individual with osteogenesis imperfecta type IV was a mixture of normal molecules and molecules that were post-translationally overmodified. The individual was heterozygous for a G to A transition in the COL1A1 gene that resulted in the substitution of serine for glycine 883 in one or both of the pro alpha 1 (I) chains. The thermal stability of molecules containing overmodified chains was lower by 2 degrees C than that of normal molecules. However, following cleavage of the molecules with vertebrate collagenase, the temperature of denaturation of the overmodified A fragments (residues 1-775 of the helix did not contain the substitution) was 2 degrees C greater than that of A fragments from normal molecules. The rates of cleavage by procollogen N-proteinase (EC 3.4.214.14) (N-proteinase) of procollagen molecules in normal and osteogenesis imperfecta samples were not significantly different. The procollagen molecules in the osteogenesis imperfecta sample were also indistinguishable from those in control samples by rotary shadowing electron microscopy. The results suggest that this substitution of serine for glycine in the alpha 1 (I) chain of procollagen, like the substitution of aspartate for the same glycine previously described (Lightfoot, S. J., Holmes, D. F., Brass, A., Grant, M. E., Byers, P. H., and Kadler, K. E. (1992) J. Biol. Chem. 267, 25521-25528), can alter the structure of the triple helix N-terminal to the site of the substitution. However, in contrast to the aspartate for glycine substitution, the structural change is insufficient to delay the cleavage of the procollagen by N-proteinase and results in a mild rather than lethal phenotype.

Amino Acid Sequence↗

[Osteogenesis imperfecta in monozygotic twins in Burundi].

Little data is available about osteogenesis imperfecta in Black African children. This defect was diagnosed in monozygotic twins from Rwanda who presented multiple fractures, in particular of the femur, when they began to walk. Osteogenesis imperfecta was confirmed by lower limb deformity, presence of wormian bones in the skull, blue sclera, and tooth defects. In addition to the fact that it is uncommon to encounter this condition in monozygotic twins, this case is interesting for several reasons. Was osteogenesis imperfecta in these patients type I, frequent, or type III, exceptional? More importantly, this case stresses the high prevalence of type III in Black Africa which could constitute a hot-bed in the world.

Child, Preschool↗