rickets
TRANSCRIPT
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/985510-overview
http://www.cdc.gov/breastfeeding/recommendations/vitamin_d.htm