Osteogenesis Imperfecta (OI)

Updated: Mar 03, 2022
  • Author: Manoj Ramachandran, MBBS, MRCS, FRCS; Chief Editor: Harris Gellman, MD  more...
  • Print

Practice Essentials

Osteogenesis imperfecta (OI) is a disorder of bone fragility chiefly caused by mutations in the COL1A1 and COL1A2 genes that encode type I procollagen. Four types of OI were originally described by Sillence in 1979 and are now used broadly as the Sillence criteria. [1]  The Nosology and Classification of Genetic Skeletal Disorders provided similar categorization in the 2019 revision, while also listing various additional types grouped under the four major types. [2]  Precise typing is often difficult and depends in large degree on the experience of the clinician. Severity ranges from mild forms to lethal forms in the perinatal period.

Additional genes have been discovered in which mutations can also cause brittle bones. These typically are clinically indistinguishable and are considered by most to be subtypes of OI.

The earliest known case of OI is in a partially mummified infant’s skeleton from ancient Egypt now housed in the British Museum in London. In 1835, Lobstein coined the term osteogenesis imperfecta and was one of the first to correctly understand the etiology of the condition. Other names for OI are Lobstein disease, brittle-bone disease, blue-sclera syndrome, and fragile-bone disease.

OI is one of the most common skeletal dysplasias. It is a generalized disease of connective tissue that may manifest itself with one or more of the following findings:

  • Blue sclerae
  • Triangular facies
  • Macrocephaly
  • Hearing loss
  • Defective dentition
  • Barrel chest
  • Scoliosis
  • Limb deformities
  • Fractures
  • Joint laxity
  • Growth retardation

Additional features, such as constipation and sweating, may also occur.

Because OI is a genetic condition, it has no cure. A multidisciplinary approach is required to manage the disease. [3, 4, 5, 6, 7]  Medical treatments aimed at increasing bone mass and strength have gained popularity. [8, 9]  Orthotics play a limited role in management of OI and are used to stabilize lax joints and to prevent progressive deformities and fractures. It is more important to provide walking aids, specialized wheelchairs, and home adaptation devices to help improve the patient’s mobility and function. Surgery remains a pillar of treatment, [10, 7] but it should be performed only if it is likely to improve function and only if the treatment goals are clear.



In OI, pathologic changes are seen in all tissues of which type 1 collagen is an important constituent (eg, bone, ligament, dentin, and sclera). The basic defect is one of a qualitative or quantitative reduction in type 1 collagen. Mutations in genes encoding type 1 collagen affect the coding of one of the two genes, accounting for approximately 80% of OI cases. [11, 12, 13, 14]

Most cases of OI, previously thought to be either autosomal dominant or autosomal recessive, are now known to arise from autosomal dominant mutations. These mutations are either genetically inherited or new. The inherited mutations have a recurrence risk in subsequent pregnancies of 50% if a parent is affected, whereas the new mutations have an unpredictable recurrence risk.

A small number of cases previously thought to be autosomal recessive have now been proved by molecular and linkage analysis to be secondary to gonadal mosaicism. The recurrence risk for these cases is also unpredictable.

In bone, the degree of histologic change correlates well with the clinical severity of the disease. The disease affects both endochondral and intramembranous ossification.

In OI due to quantitative defects of type 1 collagen, a mild form of the disease occurs. On light microscopy, osteoporotic bone is present, with thick osteoid seams and reduced intercellular matrix. The numbers of osteoclasts and osteocytes are normal. Bone trabeculae are thin and disorganized. Lamellar bone is seen in the diaphysis and metaphysis. On electron microscopy, osteoblasts show distended rough endoplasmic reticulum (possibly because of accumulation of incomplete procollagen molecules), and collagen fibers are of reduced diameter.

In OI due to qualitative defects of type 1 collagen, a severe form of the disease occurs. Light microscopy reveals hyperosteocytosis and increased vascular channels. Other findings are reduced cortical bone thickness, lack of normal cortical bone formation, and disorganization of the growth plate. Woven bone is seen, with minimal osteoid bone and no lamellar bone. Electron microscopy shows poorly preserved osteoblasts and collagen bundles of variable diameter, particularly in the more lethal forms of OI.

The epiphysis and physis tend to be broad and irregular, with disorganization of the proliferative and hypertrophic zones and loss of the typical columnar arrangement. Thinning of the zone of calcified cartilage is evident, along with deficiency of the primary spongiosa of the metaphysis and delay of the secondary centers of ossification in the epiphysis.

With respect to the axial skeleton, scoliosis and kyphosis are common. Vertebral bodies tend to be wedged, translucent, and shallow. Thinning of the skull and multiple ossification centers (wormian bones) are present, particularly in the occiput.



Type 1 collagen is a triple helix formed by two copies of the alpha1 chain and one copy of the alpha2 chain. The COL1A gene on chromosome 17 encodes the pro-alpha1 chain, and the COL2A gene on chromosome 2 encodes the pro-alpha2 chain. [15]

The gene sequence coding for the triple-helix domain has a repeating motif of (Gly-X-Y)(n), where X is commonly hydroxyproline and Y is commonly hydroxylysine. Glycine, being the smallest of all amino acids, fits into the core of the superhelix when the chains wind around each other; therefore, glycine plays an important role in the superhelix formation.

In 85-90% of cases, the gene mutation occurs in the region where the exon and intron splice sites are sequenced. All current mutations for type 1 collagen and their associated phenotypes can be found in the Human Type 1 Collagen Mutation Database.

In OI due to quantitative defects of type 1 collagen, mutations are usually found on the COL1A gene. The mutations result in the production of a premature stop codon or a microsense frame shift, which leads to mutant messenger RNA (mRNA) in the nucleus. However, the cytoplasm contains normal alpha1 mRNA; therefore, reduced amounts of structurally normal collagen are produced.

In OI due to qualitative defects of type 1 collagen, autosomal dominant mutations are found on either the COL1A or the COL1B gene. The mutations result in the production of a mixture of normal and mutant collagen chains. Substitution of a larger amino acid (eg, cysteine or alanine) for glycine results in abnormal helix formation, but these chains can combine with normal chains to produce type 1 collagen. The type 1 collagen thus formed is functionally impaired because of the mutant chain; this is the so-called dominant negative mechanism.

Wallace et al, in a report on three patients who had type I OI and primary open angle glaucoma (POAG), identified two novel mutations in COL1A1 in these individuals. [16] They suggested that some mutations in COL1A1 may be causative for OI and POAG. Alternatively, susceptibility genes may interact with mutations in COL1A1 to cause POAG.



The overall incidence of OI is approximately 1 case for every 20,000 live births; however, the mild form is underdiagnosed, and the actual prevalence may be higher. Prevalence appears to be similar worldwide, though an increased rate has been observed in two major tribal groups in Zimbabwe.

OI can present at any age, though the age when symptoms (ie, fractures) begin varies widely. Patients with mild forms may not have fractures until adulthood, or they may present with fractures in infancy. Patients with severe cases present with fractures in utero.

OI is equally common in males and females. It has been described in every human population in which skeletal dysplasias have been studied. The disease appears to have no predilection for a particular race.



Morbidity and mortality associated with OI vary widely, depending on the genotype. (See also the adapted Sillence classification in Presentation.) In addition, variability occurs between individuals with different mutations, and variability has also been observed between unrelated individuals with the same mutations, between members of the same family, and even between identical twins on occasion.

At one extreme, early stillbirths occur, and virtually every bone in the body has multiple fractures. The severe perinatal form (type II) is usually fatal within hours after birth, though some babies survive for several months. At the other extreme is OI in its mildest form. In this setting, adults who have never sustained a fracture come to medical attention only because their family members are affected. Between these extremes is a smooth continuum of severity.

The life expectancy of subjects with nonlethal OI appears to be the same as that for the healthy population, except for those with severe OI with respiratory or neurologic complications. Although patients with lethal OI may die in the perinatal period, individuals with extremely severe OI can survive until adulthood.


Patient Education

Patients with OI are generally well motivated and keen to achieve as much as possible despite their physical limitations. [17] Education is extremely important, particularly for those patients who may respond to their condition in a more negative way and therefore be prone to low self-esteem and depression.

Education of parents and families of OI patients is also important for helping them deal with the day-to-day implications and ongoing management of the disorder. For example, parents need special instructions in handling affected children. They need to know how to position the child in the crib and how to hold the child so as to minimize the risk of fractures while maintaining bonding and physical stimulation.

Living with ostogenesis imperfecta

A number of useful tips have been developed by the Osteogenesis Imperfecta Foundation for taking care of children with OI, including the following:

  • Never pull or push on a limb, or bend it into an awkward position, not even to take an x-ray
  • Use caution when inserting IVs, taking blood pressure, or performing other medical procedures to avoid causing injury
  • Always dose medicines to the size, not the age, of short statured adults
  • When a fracture is suspected, minimize handling of the affected limb
  • Respect the opinions, advice, or instructions provided by parents, children, and adults with OI, who have experience with the condition
  • Handle babies with extra care - Lift a baby with OI by placing one hand under the buttocks and legs, and the other hand under the shoulders, neck, and head, and do not lift the baby from under the armpits; do not lift by the ankles to change a diaper but,  rather, slide a hand under the buttocks; babies need not be kept on a pillow or soft surface and should be encourage babies to explore independent movement; supporting infants in a variety of positions develops muscles that will help with sitting and standing later on

A crucial point to stress is that parents should not automatically feel guilty if their child breaks a bone. Children must grow and develop, and fractures can occur despite excellent care. Because increasing awareness of child abuse and a lack of awareness about OI may lead to inaccurate conclusions about a family situation, it is worthwhile always to have a letter from the family doctor and a copy of the child's medical records handy.