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BASSEY, A E M.B, B.S
DEPARTMENT OF ORTHOPAEDIC AND TRAUMA SURGERY
U.A.T.H, GWAGWALADA
• INTRODUCTION
• DEFINITION
• STATEMENT OF IMPORTANCE
• EPIDEMIOLOGY
• METABOLIC BONE PHYSIOLOGY
• BONE COMPOSITION
• BONE MINERALISATION AND TURNOVER
• AETIOPATHOGENESIS
• MANAGEMENT
• CLINICAL ASSESSMENT
• BIOCHEMICAL ASSESSMENT
• RADIOGRAPHIC ASSESSMENT
• TREATMENT
• FOLLOW-UP
• COMPLICATIONS
• OF RICKETS
• OF TREATMENT
• PREVENTION
• CONCLUSION
 RICKETS IS A METABOLIC BONE DISEASE
UNIQUE TO CHILDREN AND ADOLESCENTS,
RESULTING FROM INADEQUATE
MINERALISATION OF OSTEOID
 IT IS THE COMMONEST METABOLIC BONE
DISEASE IN CHILDREN AND FREQUENTLY
ATTENDED BY DEFORMITIES. SURGEONS
THEREFORE, MUST HAVE ADEQUATE
KNOWLEDGE IN THE DIAGNOSIS AND
TREATMENT OF THIS PROBLEM.
 COMMONEST METABOLIC BONE DISEASE
GLOBALLY
 NUTRITIONAL TYPE IS COMMONEST IN AFRICA,
MIDDLE EAST & SE ASIA
 RENAL RICKETS COMMONEST IN THE WEST
 INCIDENCE RISING IN THE WEST DUE TO
INCREASED USE OF SUNSCREEN LOTIONS & MORE
CHILDREN STAYING INDOORS AND WATCHING TV
OR PLAYING VIDEO GAMES
BONE
MATRIX
COLLAGEN
GROUND SUBSTANCE
MUCOPOLYSACCHARIDES
(CHONDROITIN SULFATE)
PROTEINS (OSTEOPONTIN,
OSTEOCALCIN,
OSTEONECTIN, BMP)
MINERALS (CALCIUM,
PHOSPHATE, MAGNESIUM)
CELLS
OSTEOBLASTS
OSTEOCLASTS
OSTEOCYTES
 SOURCE & REGULATION OF BONE
MINERALISATION
 ROLE OF VITAMIN D
 ROLE OF PARATHYROID HORMONE
 ROLE OF CELLS IN BONE TURNOVER
 OSTEOBLASTS
 OSTEOCLASTS
 ACQUIRED
 NUTRITIONAL
 RENAL HYPOCALCAEMIA → ↓MINERALISATN
 GASTROINTESTINAL
 DRUGS
 PHENOBARB, PHENYTOIN
 CONGENITAL
 FAMILIAL HYPOPHOSPHATAEMIC RICKETS
 ENZYME DEFICIENCIES
 CLINICAL ASSESSMENT
◦ HISTORY
 AGE – CHILD/ADOLESCENT
 DEFORMITY OF THE LOWER LIMBS
 SHORT STATURE
 LISTLESSNESS
 SEIZURES
 NUTRITION – MALNUTRITION, VEGAN, PROLONGED
BREASTFEEDING WITHOUT SUPPLEMENTATION
 FAMILY HISTORY
 DRUG HISTORY
◦ EXAMINATION
 ↓HEIGHT-FOR-AGE
 GENERALISED HYPOTONIA
 DELAYED CLOSURE OF ANTERIOR FONTANELLE
 THICKENING OF WRIST JOINT, KNEE, ANKLE
◦ EXAMINATION
 LOWER LIMB DEFORMITIES – BOWING OF FEMUR/TIBIA,
GENU VALGUM
 RACHITIC ROSARY
 HARRISON SULCUS
 KYPHOSCOLIOSIS (ESP. ABOVE 2 YEARS)
 SERUM CALCIUM
 SERUM PHOSPHATE
 Ca x P PRODUCT
 ALKALINE PHOSPHATASE
 25-HYDROXYCHOLECALCIFEROL
 SERUM E/U/Cr
 URINALYSIS
 SPLAYING, CUPPING AND FRAYING OF
METAPHYSES
 OSTEOPENIA
 BONY DEFORMITIES
 CRANIOTABES
 PATHOLOGIC FRACTURES
 TREATMENT IS MEDICAL
 CHOLECALCIFEROL 2000 – 5000IU/DAY +
CALCIUM SUPPLEMENTS
 IN RENAL RICKETS, HIGH DOSES –
CHOLECALCIFEROL 150,000IU + Ca.
CALCITRIOL MAY BE GIVEN AS WELL
 RESIDUAL DEFORMITY IS CORRECTED
SURGICALLY (OSTEOTOMY)
 CLINICAL
 COMPLIANCE
 IMPROVEMENT IN DEFORMITY
 COMPLICATIONS
 INVESTIGATIONAL
 SERUM CALCIUM
 SERUM PHOSPHATE FORTNIGHTLY
 ALKALINE PHOSPHATASE
 DUE TO DISEASE
◦ RESIDUAL DEFORMITY
◦ PATHOLOGIC FRACTURE
◦ COMPLICATED CHILDBIRTH
◦ RESPIRATORY FAILURE
 DUE TO TREATMENT
◦ HYPERCALCAEMIA
◦ NEPHROCALCINOSIS
◦ UROLITHIASIS
 PARENT EDUCATION
 ADEQUATE EXPOSURE TO SUN
 AVOID USE OF SUNSCREEN LOTIONS
 DIETARY SOURCES - OILY FISH (MACKEREL, TUNA),
COD LIVER OIL, EGG YOLK, BEEF LIVER
 BREAST MILK CONTAINS VIT D 20-40IU/L
 THE AMERICAN ACADEMY OF PAEDIATRICS (2008)
RECOMMENDS:
◦ BREASTFED INFANTS TO RECEIVE 400IU VIT D/DAY
◦ WHEN WEANED SHOULD BE PLACED ON VIT D-FORTIFIED
FORMULA OR FOR AN OLDER CHILD FORTIFIED MILK
 NUTRITIONAL RICKETS REMAINS A COMMON
PROBLEM IN OUR ENVIRONMENT.
 DESPITE ITS TREATMENT BEING QUITE OFTEN
REWARDING, GREATER AMOUNT OF EFFORT
NEED TO BE GEARED TOWARD ITS
PREVENTION IN OUR POPULACE.
THANK YOU
 APLEY’S SYSTEM OF ORTHOPAEDICS &
FRACTURES, 9th Ed, pp 117-142
 PRINCIPLES & PRACTICE OF SURGERY, BADOE
et al, 4th Ed, pp 1167-1169
 BAILEY & LOVE’S SHORT PRACTICE OF
SURGERY, 25TH Ed, pg 566
 CHAPMAN’S ORTHOPAEDIC SURGERY, 3RD Ed,
pp 4588 – 4590
 http://emedicine.medscape.com/article/985
510-overview
 http://www.cdc.gov/breastfeeding/recomme
ndations/vitamin_d.htm

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Rickets

  • 1. BASSEY, A E M.B, B.S DEPARTMENT OF ORTHOPAEDIC AND TRAUMA SURGERY U.A.T.H, GWAGWALADA
  • 2. • INTRODUCTION • DEFINITION • STATEMENT OF IMPORTANCE • EPIDEMIOLOGY • METABOLIC BONE PHYSIOLOGY • BONE COMPOSITION • BONE MINERALISATION AND TURNOVER • AETIOPATHOGENESIS • MANAGEMENT • CLINICAL ASSESSMENT • BIOCHEMICAL ASSESSMENT • RADIOGRAPHIC ASSESSMENT • TREATMENT • FOLLOW-UP • COMPLICATIONS • OF RICKETS • OF TREATMENT • PREVENTION • CONCLUSION
  • 3.  RICKETS IS A METABOLIC BONE DISEASE UNIQUE TO CHILDREN AND ADOLESCENTS, RESULTING FROM INADEQUATE MINERALISATION OF OSTEOID  IT IS THE COMMONEST METABOLIC BONE DISEASE IN CHILDREN AND FREQUENTLY ATTENDED BY DEFORMITIES. SURGEONS THEREFORE, MUST HAVE ADEQUATE KNOWLEDGE IN THE DIAGNOSIS AND TREATMENT OF THIS PROBLEM.
  • 4.  COMMONEST METABOLIC BONE DISEASE GLOBALLY  NUTRITIONAL TYPE IS COMMONEST IN AFRICA, MIDDLE EAST & SE ASIA  RENAL RICKETS COMMONEST IN THE WEST  INCIDENCE RISING IN THE WEST DUE TO INCREASED USE OF SUNSCREEN LOTIONS & MORE CHILDREN STAYING INDOORS AND WATCHING TV OR PLAYING VIDEO GAMES
  • 5. BONE MATRIX COLLAGEN GROUND SUBSTANCE MUCOPOLYSACCHARIDES (CHONDROITIN SULFATE) PROTEINS (OSTEOPONTIN, OSTEOCALCIN, OSTEONECTIN, BMP) MINERALS (CALCIUM, PHOSPHATE, MAGNESIUM) CELLS OSTEOBLASTS OSTEOCLASTS OSTEOCYTES
  • 6.  SOURCE & REGULATION OF BONE MINERALISATION  ROLE OF VITAMIN D  ROLE OF PARATHYROID HORMONE  ROLE OF CELLS IN BONE TURNOVER  OSTEOBLASTS  OSTEOCLASTS
  • 7.  ACQUIRED  NUTRITIONAL  RENAL HYPOCALCAEMIA → ↓MINERALISATN  GASTROINTESTINAL  DRUGS  PHENOBARB, PHENYTOIN  CONGENITAL  FAMILIAL HYPOPHOSPHATAEMIC RICKETS  ENZYME DEFICIENCIES
  • 8.  CLINICAL ASSESSMENT ◦ HISTORY  AGE – CHILD/ADOLESCENT  DEFORMITY OF THE LOWER LIMBS  SHORT STATURE  LISTLESSNESS  SEIZURES  NUTRITION – MALNUTRITION, VEGAN, PROLONGED BREASTFEEDING WITHOUT SUPPLEMENTATION  FAMILY HISTORY  DRUG HISTORY ◦ EXAMINATION  ↓HEIGHT-FOR-AGE  GENERALISED HYPOTONIA  DELAYED CLOSURE OF ANTERIOR FONTANELLE  THICKENING OF WRIST JOINT, KNEE, ANKLE
  • 9. ◦ EXAMINATION  LOWER LIMB DEFORMITIES – BOWING OF FEMUR/TIBIA, GENU VALGUM  RACHITIC ROSARY  HARRISON SULCUS  KYPHOSCOLIOSIS (ESP. ABOVE 2 YEARS)
  • 10.
  • 11.
  • 12.
  • 13.
  • 14.
  • 15.  SERUM CALCIUM  SERUM PHOSPHATE  Ca x P PRODUCT  ALKALINE PHOSPHATASE  25-HYDROXYCHOLECALCIFEROL  SERUM E/U/Cr  URINALYSIS
  • 16.  SPLAYING, CUPPING AND FRAYING OF METAPHYSES  OSTEOPENIA  BONY DEFORMITIES  CRANIOTABES  PATHOLOGIC FRACTURES
  • 17.
  • 18.
  • 19.  TREATMENT IS MEDICAL  CHOLECALCIFEROL 2000 – 5000IU/DAY + CALCIUM SUPPLEMENTS  IN RENAL RICKETS, HIGH DOSES – CHOLECALCIFEROL 150,000IU + Ca. CALCITRIOL MAY BE GIVEN AS WELL  RESIDUAL DEFORMITY IS CORRECTED SURGICALLY (OSTEOTOMY)
  • 20.  CLINICAL  COMPLIANCE  IMPROVEMENT IN DEFORMITY  COMPLICATIONS  INVESTIGATIONAL  SERUM CALCIUM  SERUM PHOSPHATE FORTNIGHTLY  ALKALINE PHOSPHATASE
  • 21.  DUE TO DISEASE ◦ RESIDUAL DEFORMITY ◦ PATHOLOGIC FRACTURE ◦ COMPLICATED CHILDBIRTH ◦ RESPIRATORY FAILURE  DUE TO TREATMENT ◦ HYPERCALCAEMIA ◦ NEPHROCALCINOSIS ◦ UROLITHIASIS
  • 22.  PARENT EDUCATION  ADEQUATE EXPOSURE TO SUN  AVOID USE OF SUNSCREEN LOTIONS  DIETARY SOURCES - OILY FISH (MACKEREL, TUNA), COD LIVER OIL, EGG YOLK, BEEF LIVER  BREAST MILK CONTAINS VIT D 20-40IU/L  THE AMERICAN ACADEMY OF PAEDIATRICS (2008) RECOMMENDS: ◦ BREASTFED INFANTS TO RECEIVE 400IU VIT D/DAY ◦ WHEN WEANED SHOULD BE PLACED ON VIT D-FORTIFIED FORMULA OR FOR AN OLDER CHILD FORTIFIED MILK
  • 23.  NUTRITIONAL RICKETS REMAINS A COMMON PROBLEM IN OUR ENVIRONMENT.  DESPITE ITS TREATMENT BEING QUITE OFTEN REWARDING, GREATER AMOUNT OF EFFORT NEED TO BE GEARED TOWARD ITS PREVENTION IN OUR POPULACE.
  • 25.  APLEY’S SYSTEM OF ORTHOPAEDICS & FRACTURES, 9th Ed, pp 117-142  PRINCIPLES & PRACTICE OF SURGERY, BADOE et al, 4th Ed, pp 1167-1169  BAILEY & LOVE’S SHORT PRACTICE OF SURGERY, 25TH Ed, pg 566  CHAPMAN’S ORTHOPAEDIC SURGERY, 3RD Ed, pp 4588 – 4590  http://emedicine.medscape.com/article/985 510-overview  http://www.cdc.gov/breastfeeding/recomme ndations/vitamin_d.htm