Updated: 10/10/2016

Scurvy

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https://upload.orthobullets.com/topic/9034/images/scurvy xr1.jpg
https://upload.orthobullets.com/topic/9034/images/scurvy knee.jpg
https://upload.orthobullets.com/topic/9034/images/scurvy wrist.jpg
https://upload.orthobullets.com/topic/9034/images/scorbutic rosary.jpg
https://upload.orthobullets.com/topic/9034/images/rachitic rosary.jpg
https://upload.orthobullets.com/topic/9034/images/wimberger.jpg
Introduction
  •  Definition
    • Vitamin C (ascorbic acid) deficiency
  • Epidemiology
    • incidence
      • 8% of men and 6% of women in the US have vitamin C deficiency
    • demographics
      • male: female ratio is 4:3
    • bimodal age bracket
      • infants 5-10months
        • uncommon in infants <7mths who are being breast fed as breast milk has vitamin C
      • men >60 years
    • location
      • wrists, knees, sternal ends of ribs
        • areas of rapid growth in children
    • risk factors
      • elderly, especially men who live alone
        • chronic malnutrition
        • overcooking destroys vitamin C
      • alcoholic
      • smokers
      • malabsorptive conditions (Whipple's disease, inflammatory bowel disease, cancer chemotherapy)
  • Pathophysiology
    • humans are unable to synthesize L-ascorbic acid because the enzyme L-gluconolactone oxidase is nonfunctional
    • Vitamin C deficiency leads to decrease in chondroitin sulfate and collagen synthesis and repair
    • impaired intracellular hydroxylation of collagen peptides
    • net effect is altered bone formatin with the greatest effect occuring in the metaphysis
    • defect in spongiosa of the metaphysis at the growth plate 
    • because the demand for type I collagen is greatest during new bone formation
  • Prognosis
    • excellent prognosis if treated early
Presentation
  • History
    • infant diet consisting of evaporated or condensed milk
    • "tea and toast" diet in elderly
  • Symptoms
    • malaise and fatigue
    • pain
      • bone pain
      • myalgia, because of reduced carnitine production
    • bleeding
      • gum bleeding and loosening of teeth
      • hematuria
      • hematemesis
      • hemorrhage
      • iron deficiency
  • Physical exam
    • petechiae and ecchymosis
    • joint effusions  
    • swelling over long bones because of subperiosteal hemorrhage  
    • scorbutic rosary (costochondral separation)
      • angular step-off deformity in children  
      • differentiated from rachitic rosary, which is rounded and nodular  
Imaging
  • Radiographs
    • recommended views
      • wrist radiographs
      • knee
      • sternal ends of ribs
    • findings 
      • the white line of Frankel   
        • widened zone of provisional calcification
        • between epiphysis and metaphysis
      • Trummerfeld zone  
        • transvese radiolucent band in the metaphysis adjacent to the Frankel line
        • also known as the scurvy line
      • Wimberger ring   
        • ring of increased density surrounding epiphysis
      • Pelkin spur and fracture   
        • metaphyseal spurs and fractures
      • corner sign of Park  
        • metaphyseal clefts
      • thin cortices ("pencil-point" cortex)  
      • decreased trabeculae with ground-glass osteopenia  
      • subperiosteal elevation  
      • epiphyseal separation
      • fractures and dislocations
Studies
  • The diagnosis is usually made based on history, clinical and radiological picture, and resolution of symptoms following vitamin C administration. Lab tests are usually not helpful.
  • Labs
    • fasting serum ascorbic acid level is low
  • Histology
    • replacement of primary trabeculae with granulation tissue
    • areas of hemorhage
    • widening zone of provisional calcification of the physis 
Treatment
  • Nonoperative
    • vitamin C replacement 
    • indications
      • signs and symptoms of scurvy
      • chronic malnutrition
    • techniques
      • oral vitamin C at 250mg qid x 1 week in adults
 

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Questions (1)

(OBQ08.26) A 7-year-old recent immigrant presents with pain and tenderness over the legs. Physical exam shows the gums have a bluish-purple hue with areas of hemorrhages. A radiograph is shown in Figure A. In Figure B, what region of the growth plate is most affected in this condition? Tested Concept

QID: 412
FIGURES:
1

A

6%

(97/1543)

2

B

10%

(153/1543)

3

C

19%

(290/1543)

4

D

29%

(448/1543)

5

E

35%

(544/1543)

L 4 C

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