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Rickets & osteomalacia

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Rickets & osteomalacia

  1. 1. Rickets & Osteomalacia Dr.Priyank Uniyal SR AIIMS Rishikesh
  2. 2. Sunlight as a source of vitamin D Adequate supplies of vitamin D3 can be synthesized with sufficient exposure to solar ultraviolet B radiation Melanin, clothing or sunscreens that absorb UVB will reduce cutaneous production of vitamin D3
  3. 3. Rickets & Osteomalacia These are different expression of the same disease. Lack of available calcium and phosphorus ( or both) for mineralization of newly formed osteoid . Rickets- – Occur in children – only before fusion of epiphysis – Leads to softening of bone & deformity Osteomalacia- occur in adult -softening of bone
  4. 4. Rickets & Osteomalacia Etiology Deficiency (vit – D or phosphate) – Deficient intake in diet – GI disease Renal causes – Vit – D resistent – Vit –D dependent( type – I & II) – Renal tubular acidosis – CRF Other -Chronic use of anticonvulsant drugs -fibrous dysplasia and neurofibromatosis -fibrous or connective tissue tumor
  5. 5. Normal bone growth THERE ARE 4 ZONES : 1.ZONE OF RESTING CARTILAGE : 1 layer 2.ZONE OF PROLIFERATING CART. : 6 layers 3.zone OF PROVISIONAL CALCIFICATION "epiphyseal line " : the cart. cells in this layer become mature, they contain alkaline phosphatase  release the phosphate in the matrix which already contains ca. & po4 in solution  increase production of ca. & po4  precipitation of ca.phosphate in the matrix around the cartilage cells  death of the cells. 4.ZONE OF BONE FORMATION : The layer of prov. calc. is invaded by capillaries and osteoblast which deposit a layer of organic bone matrix "osteoid tis.“  rapidly mineralized and the calcified cartilage ultimately replaced by bone.
  6. 6. PATHOLOGY 1. The mature cartilage cells will not die and the proliferating zone will be formed of many layers and invades the adjacent zone of of provis. calc.- irregularity of epiphyseal line. 2. The prov. calc. zone and newly formed ost. tis. will fail to calcify or will calcified irregularly.  wide irregular frayed zone of non rigid tis. " RACHITIC METAPHSIS " is produced. 3. In the shaft the preformed bone is replaced by uncalcified ost.  soft rarified cortical bone  bone deformities & green stick fractures.
  7. 7. Rickets  Disease of infancy &childhood Dietary deficiency & GI disease are the common causes Rare before 6 months  Commonly develop b/w 6 mth - 3yr
  8. 8. Rickets Clinical feature General  Failure to thrive  Apathetic , irritable  Shorter, lower body weight and anemic  Excessive sweating particularly at hand & face
  9. 9. Rickets Clinical feature Head craniotabes(soft skull) frontal bossing Widening of suture, persistent fontanelae Delayed dentition, caries
  10. 10. Rickets Clinical feature Chest Rachitic rosary Harrison groove Pigeon chest Respiratory infection and atelectasis
  11. 11. Rickets Characteristic feature Widening of wrist, knee and ankle due to physeal over growth
  12. 12. Rickets Characteristic feature  Abdomen - prominent  muscle weakness (floppy baby, delayed walking)  Pelvis - narrow inlet
  13. 13. Rickets Characteristic feature Deformity Toddlers: Bowed legs (genu varum)
  14. 14. Rickets Characteristic feature Deformity Older children: Knock-knees (genu valgum)
  15. 15. Rickets Characteristic feature Deformity windswept knees
  16. 16. Rickets Characteristic feature Thoracic kyphosis increased tendency for fracture, especially green stick # Growth disturbance Bone pain or tenderness tetany Sign of PEM
  17. 17. Rickets Clinical evaluation Dietary history Maternal risk factors Drugs GI disease Renal disease
  18. 18. Rickets Evaluation Initial lab. test – Serum Ca, S.Ph, alkaline phosphatase, PTH , 25 Vit-D, 1, 25 Vit-D, creatinine
  19. 19. Rickets Vit-D deficiency vit-D resistant Acquired Inherited Muscular weakness No muscular weakness Normal growth rate Growth seldom become N Serum Ph3 comes N Serum Ph3 never comes with t/t normal
  20. 20. Rickets Radiographic feature
  21. 21. Rickets Radiographic feature
  22. 22. Rickets Radiographic feature
  23. 23. Rickets Diagnosis History & physical examination finding Radiographic abnormality Special etiology confirmed with lab. test
  24. 24. Rickets Biochemical finding Most specific test for vit–D deficiency is 25 vit–D PTH is under -ve feedback of Calcium ● Decrease serum Ca = increase PTH Alkaline phosphatase increase in all cases of rickets and osteomalacia
  25. 25. Rickets1) Biochemical finding Category Serum Calcium Serum Ph3 Serum Alkaline Ph3ase PTH 25-HC 1, 25- DHC Tubular Reabsrp. Of Ph3 Urinary calcium Vit-D deficiency Low to normal Low High High Low Low Low low Ph3 deficiency normal Low High normal normal normal High High Gastrointestinal Low Low High High Low to Normal Low to Normal Low Low Vit- D resistant phosphoturia Normal Low High Normal Normal Norma l Low Normal Type-I dependent Low Low High High Normal Low Low low Type –II vit-D dependent low low High High N- High N- High Low low Renal tubular acidosis Low Low High High N –High N- High Low high
  26. 26. Osteomalacia Clinical feature  Insidious course  Pt may present with bone pain, backache and bone tenderness  proximal muscle weakness  Fracture may be first sign of Osteomalacia  Vertebral collapse, kyphosis
  27. 27. Osteomalacia Clinical feature Long standing case sign of secondary hyperparathyroidism ● Depression ● Polyuria ● Increased thirst ● Constipation ● Nephrolithiasis ● ?Peptic Ulcer Disease
  28. 28. Osteomalacia X- ray Looser zone
  29. 29. Osteomalacia X- ray -Looser zone
  30. 30. Osteomalacia X- ray lateral indentation of the acetabulam (trefoil pelvis) Biconcave vertebrae
  31. 31. Osteomalacia Long standing case sign of secondary hyperparathyroidism
  32. 32. Osteomalacia Long standing of Osteomalacia Cortical erosion Pathological # Brown tumor
  33. 33. Osteomalacia Deferential diagnosis 1. Osteomalacia osteoporosis Unwell well Generalized chronic ache pain after # Muscles weakness muscle normal Looser’s zone absent Ph3 decrease normal Alk. Ph3ase increase normal
  34. 34. Rickets & Osteomalacia Treatment Depending on etiology, severity and metabolic abnormality In general the combination of Vit-D, Ca and phosphate
  35. 35. Rickets Treatment Depending on etiology, severity and metabolic abnormality In general the combination of Vit-D, Ca and phosphate Orthopedic measure require in very less no. of cases 1 mg of vit-D = 40,000 IU 1 IU = 0.025 microgram
  36. 36. Rickets Treatment 1. Vit-D deficiency state Vit –D 300,000-600,000 IU Im /Orally in a day (2-4dose) Vit –D 2,000 – 5,000 I.U./day 4- 6 wk Calcium --- 1g/ day  General nutrition , sunlight ? Followed by 400 IU / day
  37. 37. Rickets Treatment 2. Absorption defect  Vit- D 1,500 – 25,000 IU / day  Calcium 1 g/ day  Treatment of underling pathology; where appropriat, low fat or gluten free diet
  38. 38. Rickets Treatment 3. Vit – D resistant Vit – D 20,000- 60,000 IU/day Or dihydrotachysterol (dose 1/3 of vit D) Neutral phosphate-1.5- 6 g/ day (4-5 dose) Calcium – 1 g / day
  39. 39. Rickets Treatment 4. Vit – Dependent type – I  1, 25 Vit – D 250 IU – 800 IU /day  Calcium 1 g/day
  40. 40. Rickets Treatment 5. Vit – Dependent type – II Respond with high dose of  1, 25 Vit – D  1,000- 20,000 IU /day for 3-6 mth  Calcium - - 1-3 g / day i/v Ca with oral supplement
  41. 41. Evaluation of treatment Serum and urinary Ca measurement  Most efficacious method to monitor t/t resolution of Vit – D deficiency  Normal 24 hr urinary Ca excretion = 100 – 250 mg When serum alkaline Ph3ase Inorganic phosphate comes normal – X- ray show sign of healing
  42. 42. Evaluation hazards ● Serum Ca > 11mg/dl ● Urinary Ca excretion > 250 mg / 24 hr increase chance of soft tissue calcification & nephrocalcinosis
  43. 43. TOXICITY • Hypervitaminosis D causes hypercalcemia, which manifest as: Nausea & vomiting Excessive thirst & polyuria Severe itching Joint & muscle pains Disorientation & coma.
  44. 44. Vitamin D Toxicity Calcification of soft tissue Lungs, heart, blood vessels Hardening of arteries (calcification) Hypercalcemia Normal is ~ 10 mg/dl Excess blood calcium leads to stone formation in kidneys Lack of appetite Excessive thirst and urination
  45. 45. Orthopedic measurement Deficiency rickets If t/t given earlier, deformity correct spontaneously
  46. 46. Orthopedic measurement Long standing case and Vit-D resistant rickets Mild deformity----------brace ● (Mermaid splint for knock knee) If deformity is mark----osteotomy
  47. 47. HOW SHOULD WE ASSESS VITAMIN D STATUS? Vitamin D2 half life <24 hrs Vitamin D3 half life <21-30 days
  48. 48. WHO SHOULD BE TESTED FOR VITAMIN D DEFICIENCY
  49. 49. HOW DO WE TREAT?
  50. 50. Thank You

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