Rickets Flashcards
what is the requirement of vitamin D of full term and when to start?
400IU\10ug\at birth
requirement of preterm , twins and low birth weight of vitmain D and when ?
400-800IU\at the age of 1 month
what is the normal serum calcium
9-11mg\dl
normal serum of phosphate
4.5-5.5 mg\dl
what is the structure of normal bone
matrix osteoid and minerals
what are the bone layers
zone of resting cartilage :1layer
zone of profilerating cartilage:6-8
zone of degenerating cartilage:deposition of Ca and ph
zone fo calcification: invasion by BV and osteoblasts with minerlaization
define rickets
Defective minerlaization of the growing bone so disease of childhood
pathophysiology of rickets
- proliferation without ossification
- epiphysis : failure of ca and ph depostion in the cartilage cells leading fo excess cartilage that invade the metaphysis(broadening and fraying
- diaphysis : bone rarefaction and fracture
types of rickets 4
- vitamin D deficiency rickets with 2ry ++parathyroidism:
a. –intake of vitD b.malabsorption(small, large, liver, panceras
c. hepatic disease(activation d. renal osteodystrophy(activation - primary PO4 deficiency no 2ry ++parathyroid:
a. X-linked hypophosphatemic rickets a. Fanconi syndrom: PCT dysfunction(gluco, phosphato, amino, uria - end organ resistance to vit D
- hypophosphatasis
types of rickets according to nutrition : and compare
nutritional vitamin D deficiency rickets : more common , 6month -2years , response to vitD good
Non-nutritional vit D de ric: less common , any age , poor
etiology of nutritional vit D D rickets
a. inadequate intake of vit D : prolonged exclusive breast milk
cow milk: non optimum ca\ph ratio
b. inadequate sun exposure:
Wrapping Winter Windows Dark skinned people
what is the rachitogenic diet
deficient in vit D ,, deficient in Ca and PO4
non optimum ca:p ratio +++ content of phytate or oxalates
what is the first sign to appear in rickets
craniotabes
what is the first sign to appear in rickets
craniotabes
what are the CP of the head in the skeletal rickets 5
- crainotabes: ping-pong ball sensation on pressing over the occiput=thinning
- frontal bossing
- macrocephaly
4, delayed closure of AF - delayed dentition
CP of limbs in rickets4
1.broadening of the ends of long bones
2.marfan sign: transverse groove across medial malleolus
3. deformities of the UL: convexity of the forearm if crawling
4. deformities of the LL:
genu varum: bow legs
genu valgum: knock knees
genu recurvatum: overextension of the knees
CP of chest in rickets 4
- rosary beads: cartilage proliferation at the costochondral junctions
- pigeon chest: ++AP diameter of the chest : protrusion of the sternum+rib flaring
- harrison sulcus:horizontal groove along the costal insertion of the diaphragm
- longitudinal sulcus: vertical groove behind rosary beads
cp of spine in rickets 4
due to laxity of ligament
kyphosis:correctable:DD of pott disease
scoliosis
kyphoscoliosis
lumber lordosis
CP of pelvis in rickest
contracted plevis important in females
CP of muscles and ligaments in rickets 3
hypotonia due to hypophosphatemia leading to
Delayed Downward Distension
1. delayed motor milestones;sitting , crawling , standing, walking
2. downward displacement of liver and spleen(visceroptosis)
3. abdominal distension dueto: hypotonia, visceroptosis not enlargement, constipation
why ca is usually normal in rickets
due to 2ry hyperparathyroidism
neurological manifestion in rikcets 2
- anorexia, irritability , sweating
- hypocalcemic tetany
causes of hypocalcemia in rickets
parathyriod gland exhaustion
bone depletion: prolonged untreated
vit D:IM massive dose ; due to rapid mobilization of ca from blood to bone
massive dose of vit D lead to hypocalciema
rapid mobilization of ca from blood to bone
latent tetany:serum, signs
Ca=7-9mg
asymptomatic, only elicited by provocation
signs of latent tetany
chvostek sign: tapping of the facial nerve=twitches fo facial muscles
trousseau sign:constriction of the UL by sphygmomanometer:carpal spasm
peroneal sign: tapping of the peroneal nerve: pedal spasm
manifest tetay :serum
Ca;less than 7gm
carpopedal spasm
laryngospasm
convulsions
manifest tetay :serum
Ca;less than 7gm
carpopedal spasm
laryngospasm
convulsions
DD of rickets
- delayed closure of AF
- delayed dentition:rickets, ostogenesis imperfecta, down syndrom, hypothyroidism
intracranial causes of macrocephaly(in AF only) - delayed walking
causes of delayed walking :neuro, bone, traing
- neurological(central,periphral:
cerebral palsy
mental retardation
hydrocephalus
neuromusclar disorders
2.bone:rickets, trauma, fractures - training : by exclusion
causes of chest infection in rickets
hyptonia:weak cough
chest deformities
causes of chest infection in rickets
hyptonia:weak cough
chest deformities
complications of rickets 7
- respiratory; chest infection, atelectasis
- neurological: tetany, convulsions, laryngospasm
- short stature:disproportionate
4.bone fractures and deformities
5.iron deficiency anemia: breast milk - contracted pelvis:obstructed labor in female
- complications of treatment:++vit D
what is the type of short stature in rickets
disproportional
investigations in rickets
1.laboratory:
serum Ca: usually normal ex in bone depletion, parp exuation, high dose of vit D
serum phosphorus:–decreased
serum alkaline phosphatase:++ increases Earliest manifestation
2. imaging:radiological improvment after 2 wks of vit D therapy
what is the earliest laboratory manifestation in rickets
++ alkaline phosphtase
when the improvment start to appear after ttt with D
2 weeks
see table in 67 rickets
prevention of rickets
nutritional education : breast, weaning, diet rich in D, avoid rachitogenic diet
vit D supplementation
sun exposure
dose and duration of vit D oral
3000-5000IU\day
2-4 weeks
dose and duration of vit D oral
3000-5000IU\day
2-4 weeks
dose duration advantages and dis of parenteral vit D3
600.000IU shock therapy
duration:single IM dose
adv:rapid, need no compliance, diagnosis of non vitamin D deficiency rickets
dis:tetany, ++D
ttt of complication:tetany, deformities
iv Ca gluconate 10% 1ml\kg slowly
orthopedic care after complete bone healing
CP of hypervitaminosis of vit D
Git:anorexia, nausea, vomiting, constipation
renal: polyuria, polydipsia, renal stones
ttt of vit D ++
stop fluid steroids
calssification of non nutritional vit D D rickets
renal malabsorpstion hepatic
renal rickets
a. glomerular:renal osteodystrophy:
defective activation by 1 a
chronic kideny disease
b. tubular:
x-linked hypophosphatemic rickets
fanconi syndrom
cystinosis: fanconi+ corneal cystine crystal
lowe syndrome: oculo- cerebro- renal:glucoma and cataract-MR-fanconi
malabsorption in rickets
cystic fibrosis
celiac disease
cholestasis
hepatic rickets
chronic liver disease:defective 25 hydr
hepatic rickets
chronic liver disease:defective 25 hydr
