Osteogenesis imperfecta (OI and sometimes known as Brittle

Bone Disease, or "Lobstein syndromeis a genetic bone disorder. People

with OI are born with defective connective tissue, or without the ability to make it, usually
because of a deficiency of Type-I collagen. This deficiency arises from an amino acid
substitution of glycine to bulkier amino acids in the collagen triple helix structure. The larger
amino acid side-chains create steric hindrance that creates a "bulge" in the collagen complex. As
a result, the body may respond by hydrolyzing the improper collagen structure. If the body does
not destroy the improper collagen, the relationship between the collagen fibrils and
hydroxyapatite crystals to form bone is altered, causing brittleness.
As a genetic disorder, OI is an autosomal dominant defect. Most people with OI receive it from a
parent but it can be an individual (de novo or "sporadic") mutation.
Type I
Collagen is of normal quality but is produced in insufficient quantities:
• Bones fracture easily
• Slight spinal curvature
• Loose joints
• Poor muscle tone
• Discolouration of the sclera (whites of the eyes), usually giving them a blue-gray color.
The blue-gray color of the sclera is due to the underlying choroidal veins which show
through. This is due to the sclera being thinner than normal because of the defective Type
I Collagen not forming correctly.
• Early loss of hearing in some children
• Slight protrusion of the eyes
IA and IB are defined to be distinguished by the absence/presence of dentinogenesis imperfecta
(characterized by opalescent teeth; absent in IA, present in IB). Life expectancy is slightly
reduced compared to the general population due to the possibility of fatal bone fractures and
complications related to OI Type I such as Basilar invagination.[citation needed]
Type II
Collagen is not of a sufficient quality or quantity
• Most cases die within the first year of life due to respiratory failure or intracerebral
hemorrhage
• Severe respiratory problems due to underdeveloped lungs
• Severe bone deformity and small stature
Type II can be further subclassified into groups A, B, C, which are distinguished by radiographic
evaluation of the long bones and ribs. Type IIA demonstrates broad and short long bones with
broad and beaded ribs. Type IIB demonstrates broad and short long bones with thin ribs that
have little or no beading. Type IIC demonstrates thin and longer long bones with thin and beaded
ribs.
Type III
Collagen quantity is sufficient but is not of a high enough quality
• Bones fracture easily, sometimes even before birth
• Bone deformity, often severe
• Respiratory problems possible
• Short stature, spinal curvature and sometimes barrel-shaped rib cage
• Loose joints
• Poor muscle tone in arms and legs
• Discolouration of the sclera (the 'whites' of the eyes)
• Early loss of hearing possible
Type III is distinguished among the other classifications as being the "Progressive Deforming"
type, wherein a neonate presents with mild symptoms at birth and develops the aforementioned
symptoms throughout life. Lifespan may be normal, albeit with severe physical handicapping.
Type IV
Collagen quantity is sufficient but is not of a high enough quality
• Bones fracture easily, especially before puberty
• Short stature, spinal curvature and barrel-shaped rib cage
• Bone deformity is mild to moderate
• Early loss of hearing
Similar to Type I, Type IV can be further subclassified into types IVA and IVB characterized by
absence (IVA) or presence (IVB) of dentinogenesis imperfecta.
Type V

OI Type V in an adult

OI Type V in a child
Same clinical features as Type IV. Distinguished histologically by "mesh-like" bone appearance.
Further characterized by the "V Triad" consisting of a) radio-opaque band adjacent to growth
plates, b) hypertrophic calluses at fracture sites, and c) calcification of the radio-ulnar
interosseous membrane
OI Type V leads to calcification of the membrane between the two forearm bones, making it
difficult to turn the wrist. Another symptom is abnormally large amounts of repair tissue
(hyperplasic callus) at the site of fractures. At the present time, the cause for Type V is unknown,
though doctors have determined that it is inherited.
Type VI
Same clinical features as Type IV. Distinguished histologically by "fish-scale" bone appearance.
Type VII
• In 2005 a recessive form called "Type VII" was discovered. Thus far it seems to be
limited to a First Nations people in Quebec For more information see Mutations in the
gene CRTAP causes this type.
Type VIII
OI caused by mutation in the gene LEPRE1 is classified as type VIII

Treatment
At present there is no cure for OI. Treatment is aimed at increasing overall bone strength to
prevent fracture and maintain mobility.
There have been many clinical trials performed with Fosamax (Alendronate), a drug used to treat
women experiencing brittleness of bones due to osteoporosis. Higher levels of effectiveness
apparently are to be seen in the pill form versus the IV form, but results seem inconclusive The
U.S. Food and Drug Administration (FDA) will not approve Fosamax as a treatment for OI
because long term effects of the drug have not been studied, although it is often used in preteens,
instead of Pamidronate Bone infections are treated as and when they occur with the appropriate
antibiotics and antiseptics.
Physiotherapy
Physiotherapy used to strengthen muscles and improve motility in a gentle manner, while
minimizing the risk of fracture. This often involves hydrotherapy and the use of support cushions
to improve posture. Individuals are encouraged to change positions regularly throughout the day
in order to balance the muscles which are being used and the bones which are under
pressure.Children often develop a fear of trying new ways of moving due to movement being
associated with pain. This can make physiotherapy difficult to administer to young children.
Physical aids
With adaptive equipment such as crutches, wheelchairs, splints, grabbing arms, and/or
modifications to the home many individuals with OI can obtain a significant degree of
autonomy.
Bisphosphonates
Bisphosphonates (BPs), particularly those containing nitrogen, are being increasingly
administered to increase bone mass and reduce the incidence of fracture. BPs can be dosed orally
(e.g. alendronate) or by intravenous injection/infusion (e.g. pamidronate, zoledronic acid).
BP therapy is being used increasingly for the treatment of OI. It has proven efficiency in
reducing fracture rates in childrenhowever only a trend towards decreased fracture was seen in a
small randomized study in adults While decreasing fracture rates, there is some concern that
prolonged BP treatment may delay the healing of OI fractures, although this has not been
conclusively demonstrated.
Pamidronate is used in USA, UK and Canada. Some hospitals, such as most Shriners, provide it
to children. Some children are under a study of pamidronate. Marketed under the brand name
Aredia, Pamidronate is usually administered as an intravenous infusion, lasting about three
hours. The therapy is repeated every three to six months, and lasts for the life of the patient.
Common side effects include bone pain, low calcium levels, nausea, and dizziness. According to
recent results, extended periods of pamidrinate, (i.e.;6 years) can actually weaken bones, so
patients are recommended to get bone densities every 6 months-1 year, to monitor bone strength.
Surgery
Metal rods can be surgically inserted in the long bones to improve strength, a procedure
developed by Harold A. Sofield, MD, at Shriners Hospitals for Children in Chicago. During the
late 1940’s, Sofield, Chief of Staff at Shriners Hospitals in Chicago, worked there with large
numbers of children with OI and experimented with various methods to strengthen the bones in
these childrenIn 1959, with Edward A. Miller, MD, Sofield wrote a seminal article describing a
solution that seemed radical at the time: the placement of stainless steel rods into the
intramedullary canals of the long bones to stabilize and strengthen them. His treatment proved
extremely useful in the rehabilitation and prevention of fractures; it was adopted throughout the
world and still forms the basis for orthopedic treatment of OI.
Spinal fusion can be performed to correct scoliosis, although the inherent bone fragility makes
this operation more complex in OI patients. Surgery for basilar impressions can be carried out if
pressure being exerted on the spinal cord and brain stem is causing neurological problems.

History and alternative names

The condition, or types of it, have had various other names over the years and in different
nations. Among some of the most common alternatives are Ekman-Lobstein syndrome, Vrolik
syndrome, and the colloquial glass-bone disease. The name "Osteogenesis Imperfecta" dates to at
least 1895and has been the usual medical term in the twentieth century to present. The current
four type system began with Sillence in 1979An older system deemed less severe types
"Osteogenesis Imperfecta Tarda" while more severe forms were deemed "Osteogenesis
Imperfecta Congenita." As this did not differentiate well, and all forms are congenital, this has
since fallen out of favour.
The condition has been found in an Ancient Egyptian mummy from 1000 BC. The Norse king
Ivar the Boneless may have had this condition as well. The earliest studies of it began in 1788
with the Swede Olof Jakob Ekman. He described the condition in his doctoral thesis and
mentioned cases of it going back to 1678. In 1831, Edmund Axmann described it in himself and
two brothers. Jean Lobstein dealt with it in adults in 1833. Willem Vrolik did work on the
condition in the 1850s. The idea that the adult and newborn forms were the same came in 1897
with Martin Benno Schmidt