Osteomalacia in a Young Adult Male Presenting as Chronic Wrist Pain: A Case Report Daniel Gonzales-Luna, MD; Dean W. Smith, MD. Department of Orthopaedic Surgery, University of Texas Health Science Center at Houston, Houston, Texas Corresponding Author Daniel Gonzales-Luna, MD. Department of Orthopaedic Surgery, University of Texas Health Science Center at Houston, 6400 Fannin Street, Suite 1700, Houston, TX 77030 (email: Daniel.C.GonzalesLuna@uth.tmc.edu). Funding The authors received no financial support for the research, authorship, or publication of this article. Conflict of Interest The authors report no conflicts of interest. Informed Consent The patient was informed that the information concerning their case would be submitted for publication, and they provided verbal consent.
ABSTRACT
CASE REPORT
Chronic wrist pain is a common problem encountered by orthopaedic surgeons, yet osteomalacia is rarely considered in the differential diagnosis in the United States. We present a case involving a 37-year-old man who experienced bilateral wrist pain and weakness for more than 2 years. Further investigation revealed a history of chronic leg pain, low serum 25-hydroxy vitamin D levels, and decreased bone density. He was diagnosed with osteomalacia and treated with vitamin D supplementation and increased sun exposure. At 6 months follow-up, the patient had resolution of his pain and normalized vitamin D levels. To our knowledge, the literature has not previously reported on osteomalacia in a young adult presenting with chronic wrist pain. Although uncommon, osteomalacia should be considered in the work-up for chronic wrist pain.
A 37-year-old man presented to the orthopaedic hand clinic with chronic wrist pain and weakness. As a software engineer, he had experienced wrist pain for the previous 2 years. The wrist symptoms occurred randomly and did not correlate with activities. He denied a history of trauma. Prior treatments were unsuccessful, including wrist bracing, workstation modifications, and cortisone injections. His medical history was significant for well-controlled hypothyroidism, childhood tuberculosis, and immigration to the United States at the age of 20 from India. On review of systems, he reported intermittent pains involving his forearms and legs with associated diffuse weakness. Physical examination of the upper extremities was within normal limits. Prior evaluation by the rheumatology service was negative for laboratory evidence of inflammatory arthritis. The rheumatologist ordered magnetic resonance imaging of both wrists, which were found to be only abnormal for diffuse cystic bone changes. Owing to his persistent wrist pain without a diagnosis, he was referred to a hand surgeon for further evaluation. After consultation, radiographs of bilateral wrists were obtained. The radiographs were concerning for osteopenia. Based on these abnormal findings, a vitamin D level and a dual-energy x-ray absorptiometry (DEXA) examination were ordered to evaluate for metabolic bone disease. The DEXA scan was consistent with osteopenia, with a T-score more than two standard deviations below the mean. His serum 25-hydroxy vitamin D level was 30 nmol/L, with less than 30 nmol/L being considered vitamin D deficient.5 Given the findings of low vitamin D levels, osteopenia on the DEXA scan, and history of chronic wrist pain and diffuse extremity pain, a preliminary diagnosis of osteomalacia was made.
Keywords: Osteomalacia, Vitamin D, Wrist
INTRODUCTION Osteomalacia is a metabolic bone disease defined by abnormal mineralization of osteoid, and it is most commonly caused by a vitamin D deficiency and hypophosphatemia.1,2 Chronic wrist pain, defined as pain lasting greater than 6 months,3 is a common concern encountered by hand specialists. Yet osteomalacia is not typically considered in the differential diagnosis.4 Symptoms of osteomalacia are often non-specific, including vague body aches and limb weakness, making diagnosis difficult.5 Osteomalacia is thought to be uncommon in the United States.5 However, recent evidence from Europe suggests that osteomalacia is often subclinical and goes undiagnosed, thus it may be more prevalent in the United States than initially thought.6 There seems to be an overall lack of awareness about osteomalacia among clinicians, thus frequently delaying diagnosis.4
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