Milkman syndrome refers to pseudofractures caused by osteomalacia. These pseudofractures are features that appear on radiologic examinations and appear white and ribbon-like on radiographs.
What is Milkman syndrome?
Milkman syndrome pseudofractures are not real fractures, but rather pathological remodeling processes in the bones, usually due to osteomalacia or a similar bone disease. They were discovered and described by Dr. Emil Looser and are therefore also called Looser remodeling processes. The symptomatology was summarized by Dr. Milkman in 1930 and is therefore also called Milkman syndrome. Milkman syndrome occurs most frequently in women between 40 and 70 years of age and is caused by a lack of density in the bone tissue. The lack of density occurs as an expression of deminalerization in the bone. In addition, densification occurs below and above the pseudofracture. Crescent-shaped calcifications, or calcareous deposits, can be observed on the substantia compacta (the outermost layer of bone below the periosteum) and show up as a deformation on the periosteum (the bone skin). The pseudofractures are mostly symmetrically located and show up in advanced stages of various bone diseases such as osteomalacia. The pseudofractures are particularly seen on the hip bone (Os coxae), ulna of the forearm (Ulnar), thigh bone (Femur), and scapula (Shoulder blade).
Causes
Milkman syndrome occurs in bone diseases such as osteomalacia and rickets, respectively. The trigger for the syndrome as well as the diseases is mostly a deficient vitamin D3 balance. Vitamin D3 is responsible for both the transport and the biologically meaningful integration of calcium. A deficiency may therefore be indicated by the Looser remodeling processes in radiological examinations. The Looser remodeling processes are accomplished by excessive activation of osteoblasts and osteoclasts. The vitamin D3 deficiency and the resulting calcium deficiency stimulate the parathyroid glands to secrete parathormone. This stimulates the formation of vitamin D3 in the kidneys and the absorption of calcium in the intestines. However, it also activates bone cells at the same time. Excessive activation of osteoblasts and osteoclasts both degrades and remodels bone material. Since a balanced vitamin D3 balance depends on several influences both inside and outside the body, a deficiency state may be due to several factors. Vitamin D is first produced in the lower skin layers of the epidermis by exposure to sunlight. Complications can arise in this process. Little time spent in the sun means low vitamin D production and favors bone diseases such as osteomalacia or osteoporosis. However, about three quarters of an hour is already sufficient to compensate for incipient deficiencies. Another important factor besides sun exposure is the effective absorption of UV-B radiation by the skin. If the skin suffers from serious damage such as severe burns, inflammation, necrosis, sufficient activation of vitamin D cannot be guaranteed. Skin and vitamin D production form a form of counter-conditionality here. Since the keratinocytes of the skin cannot produce healthy skin cells without vitamin D, and conversely, without healthy skin, effective vitamin D uptake via solar radiation is also not possible. Adequate vitamin D intake through sun exposure is also difficult here. After activation by sun exposure, the vitamin must be converted to vitamin D3 in the liver and kidneys. If organic defects such as liver cirrhosis occur here, conversion to the biologically active vitamin D3 is only possible to a limited extent.
Symptoms, complaints, and signs
Because Milkman syndrome involves pseudofractures, the typical pain associated with bone fractures does not exist. However, because the syndrome is a component of advanced osteomalacia, dull bone pain occurs simultaneously throughout the body and is often mistaken for rheumatic complaints. However, these complaints are unrelated to Milkman syndrome and are typical of acute-stage osteomalacia.
Diagnosis and course of the disease
Milkman syndrome can be detected on radiologic imaging.In particular, the Looser remodeling zones of Milkman syndrome can be observed in osteomalacia (bone softening of adults) and rickets (bone softening of children). In children with rickets, increased sweating, restlessness, and skin rash (miliaria) occur in the first months of life. Subsequently, muscle weakness and bone softening of the skull then occur. Other symptoms such as increased muscle excitability and cramps follow. The back of the head flattens and wrists and ankles show increasing widening. Other bone deformities such as O- legs centered in the long bones may occur. By this time, Milkman’s syndrome is already evident in many x-rays and Looser’s remodeling zones spread without proper treatment. Particularly serious in rickets seems to be the fact that the deficiency interferes with the child’s growth, which can cause lifelong damage. The growth plates cannot undergo such deformation in adult humans, which is the main difference of osteomalacia from rickets.
Complications
As a result of Milkman syndrome, patients experience fractures of the bones and consequent severe pain. Similarly, significant limitations in the patient’s movement occur, which can make daily life much more difficult. Likewise, most affected individuals suffer from severe headaches and bone shearing that occurs throughout the body. There is increased perspiration and general inner restlessness. It is not uncommon for patients to also suffer from psychological complaints or depression, and furthermore, muscle weakness. The patient’s ability to cope with stress decreases significantly as a result of Milkman syndrome, and it is not uncommon for cramps to occur. Pain at rest can lead to insomnia, especially at night, and thus to irritability in the patient. As a rule, Milkman syndrome can be treated relatively well and easily, with no particular complications. Life expectancy is also not usually limited by Milkman syndrome. The treatment itself takes place with the help of medication and leads quickly to success. Furthermore, there are no special complications.
When should one go to the doctor?
Since in Milkman syndrome there is no self-healing and usually a worsening of complaints and symptoms, a doctor should always be consulted for this disease. The doctor should be consulted when the affected person suffers from severe pain that may be reminiscent of a fracture or broken bone. The pain can occur in different regions and can also significantly reduce the patient’s quality of life. In many cases, the affected person suffers from restricted movement and is thus also limited in their everyday life. Likewise, rheumatic pain indicates Milkman syndrome and should be examined by a physician. Often the syndrome leads to inner restlessness or heavy sweating. Many sufferers also have a rash on the skin, which may be associated with itching. Furthermore, a doctor should also be consulted if the patient suffers from muscle weakness for no particular reason. Milkman syndrome can be diagnosed primarily by a general practitioner. However, further treatment is carried out under the supervision of various specialists and often leads to a positive course of the disease.
Treatment and therapy
For proper treatment, the origin of the deficiency symptom must first be determined. Differentiation between an organic defect and inadequate sun exposure appears particularly important for therapy. Vitamin D deficiency and a resulting disturbed calcium balance can be treated by conventional dietary supplements such as cod liver oil and vitamin D tablets. Dietary supplementation with calcium is also useful. However, extensive sunbathing is optimal for curing vitamin D deficiency symptoms. Here, again, care should be taken to ensure appropriate sun exposure, since too long and intense exposure can lead to burns, which in turn can have a negative effect on vitamin D intake and be causative of other health complaints. However, osteomalacia and rickets can also be triggered by organic disorders. A disturbed conversion process of the vitamin should therefore be clarified in advance.
Outlook and prognosis
The prognosis in Milkman syndrome depends, among other things, on the age of the patient as well as the cause. A change in diet as well as frequent exposure to the sun can very quickly stop this deficiency disorder in its tracks. It is true that some parts of the bones and joints will already be altered (Milkman syndrome could not otherwise be diagnosed at all). But a return to a healthy bone structure is possible for the body if it is supported accordingly. Vitamin D in particular is indispensable. In children, the complicating factor is that pseudofractures and the accompanying thickening of the bones interfere with development. The entire development of the skeleton can become unstable or deformed due to these bone changes. If left untreated, Milkman syndrome in children, for example, results in thickened ankles and wrists and a flat back of the head with concomitant bone softening. However, since the underlying rickets is also an expression of a deficiency symptom, these consequences can be prevented by timely treatment. Furthermore, Milkman syndrome itself almost never leads to real fractures. But rickets or osteomalacia, which is what the syndrome usually causes, do. Accordingly, affected individuals may have lifelong symptoms as a result of multiple fractures and poorly or improperly healed bones. Limitations in movement and pain are common and may persist even after therapy for Milkman syndrome.
Prevention
To prevent bone diseases such as osteomalacia, adequate sun exposure is recommended. For this purpose, even a one-hour stay in the fresh air may be sufficient. If adequate sun exposure is not available, which is especially the case in the northern hemisphere during autumn and winter, supplementation with dietary supplements is necessary.
Aftercare
Milkman syndrome, like any normal bone fracture, requires follow-up care to ensure that the fracture is healing as expected. This requires regular visits to the treating physician to clarify that no further complications are expected. The movement restrictions make everyday life more difficult, so that those affected are sometimes dependent on the help of relatives and friends. The first weeks after the occurrence of the fracture should be approached calmly, and physical exertion should be limited. However, since immobilization involves muscle loss, it is recommended to perform light exercises agreed with the doctor.
This is what you can do yourself
Milkman syndrome definitely requires a medical diagnosis. Depending on the underlying cause of the deficiency symptom, medical treatment is then given. Under certain circumstances, this can be supported by various self-help measures. In order to quickly compensate for the calcium deficit, the diet should first be changed. Calcium is found above all in kale, broccoli, Brazil nuts, yogurt and cheese – these foods should be consumed in abundance, especially in the first period after diagnosis. Food supplements such as vitamin D tablets are also recommended. Cod liver oil can also help to quickly reduce the symptoms of Milkman syndrome if taken regularly. A lack of vitamin D can be cured by extensive sunbathing. In addition, it is important to treat the individual symptoms. Bone pain requires drug therapy, which can be supported, for example, by valerian, arnica and other gentle sedatives and painkillers from nature. A proven remedy from homeopathy is belladonna, preferably in the potency D12. The doctor should approve the use of these preparations beforehand. Regular visits to the doctor are indicated anyway, as this is the only way to rule out further complications.
