Rickets and osteomalacia

1. Rickets and
Osteomalacia
Presenter: Gopal Kumar Yadav
Moderator: Dr. Amit Limbu
METABOLIC BONE
DISEASES

2. OBJECTIVES
1. Introduction and Definition
2. Causes of Rickets and Osteomalacia
3. Rickets
4. Osteomalacia

3. Introduction
•Osteomalacic diseases: These are diseases
characterized by an increase in the ratio of the
organic fraction to the mineralized fraction, i.e. the
available organic matter is undermineralized.
•Rickets: Lack of adequate mineralization of
growing bones. It occurs before closure of growth
plates.
•Osteomalacia: Lack of adequate mineralization of
trabecular bone.

5. RICKETS: Types, Clinical
features, Investigations,
Diagnosis and Treatment

6. Types of Rickets (1/2)
Classification I
• Fetal rickets-osteomalacic mothers.
• Infantile rickets-6mths to 3 yrs ,most common
form, nutritional.
• Late rickets or rachitis tarda-late onset , familial,
vitamin D resistant.

7. Types of Rickets (2/2)
Classification II
Type I Rickets: Dietary deficiency or defects in the
metabolism of vitamin D.
Type II Rickets: Low serum phosphorus due to
dietary deficiency or defective renal tubular
resorption

8. Clinical Features (1/5)
•A – Abdomen protuberant due to muscular
hypotonia
•B – Bowing of bones (on weight bearing)

9. Clinical Features (2/5)
• C – Costochondral Junction prominent - (Rosary),
Craniotabes (soft skull)

10. Clinical Features (3/5)
• D – Diaphragm pull - Harrisons groove (lateral
indentation of chest due to pull of diaphragm on
ribs)/Double malleolus d/t metaphyseal
hyperplasia

11. Clinical Features (4/5)
• E – Enamel defect of teeth and delayed dentition
• F – Forward sternum - Pigeon chest (Pectus
carinatum)
• G – Growth plate - widening

12. Clinical Features (5/5)
• H – Hypocalcemia causing Hyper PtH
• I – Irritability
• J – Joint deformities - Genu valgum/genu varum/coxa
vara
• K – Kyphosis
• L – Loosers zones
• M – Milestone delayed Muscle weakness

13. Q. In which condition is Windswept deformity seen?
some books say RA, others say Rickets? American
authors
have published RA, British have published
Rickets...which
one to pick sir?
Ans. Both diseases have wind swept deformity
Rickets at knees and at hand in RA but classically
it has been named for rickets. It is called as tackle
deformity also.

14. Investigations (1/2)
•Laboratory: Serum Ca2+, Serum PO4-,
Serum ALP

15. Investigations (2/2)
• Radiological Features: X-ray of both wrist and
knees- AP views

16. Diagnosis:
• Is based on the combination of a history of poor
vitamin D intake and risk factors for decreased
cutaneous synthesis, radiographic changes
consistent with rickets, and typical laboratory
findings .

17. Treatment: Medical (1/4)
1.Nutritional rickets: Two strategies for
administration of vitamin D.
Stoss therapy, 300,000–600,000 I.U. of vitamin D
are administered orally or intramuscularly.
The alternative is daily high dose vitamin D, 2000–
5000 I.U./day over 4–6 week.
Followed by 400 I.U. Vit D/Day and supplements of
calcium for 2–4 months

18. Treatment: Medical (2/4)
2. Hypophosphatemic Rickets
 Oral phosphate and Vit D supplements
 Joule’s Solution—Dibasic sodium phosphate,
phosphoric acid is given in hypophosphatemic
Rickets.
3. VDDR I: Calcitriol, calcium, phosphate
supplements
4. VDDR II: Treatment not satisfactory large doses

19. Treatment: Medical (3/4)
5. Renal tubular acidosis
 Bicarbonate supplements (Shohl’s solution—
Citric acid, sodium citrate) and phosphate
supplementation.
6. CRF
 Calcitriol, calcium supplements and phosphate
restriction.

20. Treatment: Orthopedic (4/4)
Conservative Methods: Designed splints
(mermaid splints) or orthopedic shoes for
correction of knee deformities
Operative methods: Corrective Osteotomies, after
6 months of starting the medical treatment

21. OSTEOMALACIA:
Clinical features,
Investigations and Treatment

22. Clinical features:
Early stages: Non-specific
Bone pains: Backache to diffuse pains
Muscle weakness: Waddling gait, Carpopedal
spasm and facial twitching
Spontaneous fractures: usually in spine

23. Investigations
Radiological Examination: Looser’s zone
(pseudo-fractures) , Triradiate pelvis and
Protrusio-acetabuli
Bone biopsy: from iliac crest confirms the
diagnosis (Excessive uncalcified osteoid)
Serum: Low serum calcium and phosphates
level, and high ALP level

24. Looser’s Zone
( Milkman’s Pseudofractures )
Pathognomonic

25. Trefoil Pelvis

26. Treatment of Osteomalacia
Identify the cause.
Vit. D 50000 IU / week X 3-12 weeks,
Followed by maintenance 400-800IU /day
Along with elemental Calcium 1.5 to 2 g / day

27. References

28. Thank You!
• To feel Low or to doubt in yourself is to commit mental
suicide which is more catastrophic than physical suicide
because mental suicide is chronic incident that melts you
daily on your voyage!
–GK Yadav