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