CALCIUM,VITAMIN D,OSTEOPOROSIS,DIET, METABOLIC BONE DISEASE,HYPERPARATHYROIDISM,RENALOSTEODYSTROPHY,RICKETS,BONEMETABOLISM,Vitamin D Resistant Rickets Type 1 & 2,Fanconi anemia,Renal tubular acidosis,Familial Hypophosphatemia Rickets,Renal Rickets,Hepatic Rickets,Malabsorption Rickets,Hypophosphatasia,Malabsorption Rickets,Metaphyseal Dysplasia,APPROACH TO CHILD WITH RICKETS,Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com.
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Approach To Child with Rickets Dr.Sandeep C Agrawal Agrasen Hospital Gondia india www.agrasenortho.com
1. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com
Dr.Sandeep Agrawal
Consultant Orthopedic Surgeon
MS,DNB
Agrasen Hospital
Gondia
Maharashtra
India
drsandeep123@gmail.com
!
www.agrasenortho.com
!
09960122234
Practical approach to Rickets
2. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com
Practical approach to child with
Rickets.
Level 1. Is it true Rickets or rickets like states ?
!
Do preliminary investigations –
Serum calcium, phosphate, Serum Alk P04ase(SAP)
!
Have a close look at the x rays
!
Consider the following conditions !
!
Hypophosphatasia
Metaphyseal dysplasia
!
3. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com
Level 1 – is it True Rickets or rickets
like states ?
Features !
!
Radiological signs similar to rickets. But growth
plate are not wide with differential involvement of
bones in a joint.!
Eg. Femur shows changes but tibia is normal.!
!
Levels of serum Ca, P and SAP normal.!
!
Diagnosis!
Metaphysial dysplasia
4. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com
Features .----
!
Clinical signs or rickets are present
but x rays show tongue like radiolucency
projecting from growth plate into metaphysis.
!
In rickets growth plate is uniformly wide.
!
SAP levels are low but S. ca, P Levels are normal.
!
!
Diagnosis
Hypophasphatasia
5. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com
Level 2 – is it nutritional or non
nutritional ?!
!
Look for clues in history or examination:!
!
Prematurity
Neonatal cholestasis
Anticonvulsant therapy
Chronic renal disease
6. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com
Level 2:
Is it nutritional or non nutritional? Useful clues
1.Jaundice - Hepatobiliary disease
Metabolic disorders
!
2.Cataract - Galactosemia, Wilson’s
!
!
3.Positive family history - Metabolic disease,
RTA
!
!
4.Mental retardation, seizures - Galactosemia
!
!
5. Drug induced rickets in primary CNS problem
!
!
6.Alopecia - VDDR type 2.
7. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com
Level 2.. Is it nutritional or non
nutritional?
In the absence of clues –!
Presume and treat it as vit D deficiency rickets.!
Give vitamin D2 (inj. arachitol) 600000 units 2 doses
at two to three weeks interval . Improvement occurs
in nutritional rickets.!
!
!
Healing is indicated by the presence of provisional
zone of calcification.!
!
Non healing favours a non nutritional cause.
8. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com
Level 2.. Is it nutritional or non
nutritional?
Features of non nutritional causes:!
!
Presentation before six months or after two years of
age!
Associated failure to thrive!
Positive family history!
Obvious clues mentioned earlier!
Failure of vitamin D therapy
9. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com
Level 3. if it is non nutritional and lack any obvious
clues it could be either due to GI or Renal cause:
Features ….!
!
Recurrent diarrhea, oily stools.
Recurrent abdominal pain and distension.
!
Anemia, hypoproteinemia.
!
Multiple vitamin and mineral deficiencies.
!
Diagonosis !
Malabsorption with rickets.
10. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com
If it is non nutritional and lack any obvious clues
it could be either due to GI or renal cause
Features …!
!
Hepatobiliary findings:!
!
Raised serum billirubin
low serum albumin
prolonged prothrombin time.
!
Diagnosis !
Hepatic rickets
11. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com
Level 3.. If it is non nutritional and lack any obvious
clues it could be either due to GI or renal cause
Features…!
Failure to thrive
Recurrent vomiting
lethargy
Acidotic breathing.
Hypertension, anemia with or without edema.
!
!
Positive findings in urine analysis.
Abnormalities in electrolytes,
Blood urea and creatinine.
Renal abnormalities in ultrasound abdomen.
!
Diagnosis!
!
Renal rickets
12. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com
Level 4.. If it is rickets due to Renal causes what is
the underlying renal problem that led to rickets.?
Depends on the clinical features of chronic
renal failure and on laboratory investigations.!
!
Do urine analysis!
Blood for electrolytes, urea and creatinine.!
Blood gas analysis.!
Ultrasonography abdomen.
13. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com
Level 3.. If it is non nutritional and lack any obvious
clues it could be either due to GI or renal cause
Features…!
!
Vomiting , lethargy, growth retardation!
Hypertension, anemia, with or without edema.!
Features of obstructive uropathy.!
Raised blood urea, creatinine.. S. potassium may be
high.!
Abnormalities in USG, MCU and DMSA scan.!
!
Diagnosis !
Chronic renal failure - renal osteodystrophy.
14. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com
Features…!
!
Recurrent vomiting, diarrhoea with acidotic
breathing.!
Positive family history.!
Metabolic acidosis with normal anion gap,
hypokalemia, and raised serum chloride!
Normal blood urea and serum creatinine.!
No proteinuria or glycosuria.!
!
Diagnosis !
Renal tubular acidosis
15. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com
Features….!
Severe form of rickets with stunting and
deformity.!
Features mentioned in RTA.!
Proteinura, glycosuria present.!
Normal or slightly increased B.urea and
S.creatinine.!
Features of underlying causes such as
cystinosis.!
!
Diagnosis!
Fanconi syndrome
16. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com
Features…!
!
Lower limb deformity, stunted growth.!
Often with family history.!
Frequent dental abscess and early decay.!
Low serum phosphate and low TRP.!
!
Diagnosis !
Familial hypophosphataemic
rickets(FHR)
17. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com
Level 5.. Child with rickets, no clues so
far, what else?
Features…!
Often presenting in early infancy!
Hypocalcemic tetany!
!
Improvement with vitamin D therapy and
recurrence of symptoms on
discontinuation.!
!
Diagnosis !
Vitamin D dependent rickets type1
18. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com
Features…!
!
Alopecia with or without any response to any
form of vitamin D!
High serum levels of 1,25 dihydroxy vitamin D!
!
Diagnosis !
Vitamin D dependent rickets type2
!
1,25(OH)2 vit D level is high in contrast to
VDDR type 1 where it is low.
19. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com
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