Rickets_Flashcards (1)

Question 1

What is rickets?

Answer 1

Rickets is a term that describes inadequately mineralised bone in developing and growing bones, resulting in soft and easily deformed bones.

Question 2

What condition in adults is equivalent to rickets?

Answer 2

The equivalent condition in adults is termed osteomalacia.

Question 3

What is the usual cause of rickets?

Answer 3

Rickets is usually due to vitamin D deficiency.

Question 4

What are some predisposing factors for rickets?

Answer 4

Predisposing factors for rickets include dietary deficiency of calcium, prolonged breastfeeding, unsupplemented cow’s milk formula, and lack of sunlight.

Question 5

What are the common features of rickets?

Answer 5

Common features of rickets include aching bones and joints, lower limb abnormalities, ‘rickety rosary’, kyphoscoliosis, craniotabes, and Harrison’s sulcus.

Question 6

What are the lower limb abnormalities associated with rickets in toddlers and older children?

Answer 6

Lower limb abnormalities associated with rickets include genu varum (bow legs) in toddlers and genu valgum (knock knees) in older children.

Question 7

What are some characteristic features of rickets seen on physical examination?

Answer 7

Characteristic features of rickets seen on physical examination include ‘rickety rosary’ (swelling at the costochondral junction), kyphoscoliosis, craniotabes (soft skull bones), and Harrison’s sulcus.

Question 8

What investigations are typically performed for rickets?

Answer 8

Investigations typically performed for rickets include measuring vitamin D levels, serum calcium, and alkaline phosphatase.

Question 9

What are the typical findings in investigations for rickets?

Answer 9

Typical findings in investigations for rickets include low vitamin D levels, reduced serum calcium, and raised alkaline phosphatase.

Question 10

What is the management for rickets due to vitamin D deficiency?

Answer 10

Management for rickets due to vitamin D deficiency includes oral vitamin D supplementation.

Question 11

What is the management for calcium-deficient rickets with vitamin D deficiency?

Answer 11

Management for calcium-deficient rickets with vitamin D deficiency includes daily calcium and ergocalciferol (vitamin D2) or colecalciferol (vitamin D3).

Question 12

What is the management for pseudo-vitamin D deficiency?

Answer 12

Management for pseudo-vitamin D deficiency (defect in 1-alpha hydroxylase) includes calcitriol or alfacalcidol.

Question 13

What is the management for hypophosphataemic rickets?

Answer 13

Management for hypophosphataemic rickets includes phosphate salts.

Question 14

What are some dietary sources of vitamin D?

Answer 14

Dietary sources of vitamin D include oily fish and egg yolk.

Question 15

summarise rickets

Answer 15

Rickets is a term that describes inadequately mineralised bone in developing and growing bones. This results in soft and easily deformed bones. It is usually due to vitamin D deficiency. In adults, the equivalent condition is termed osteomalacia

Predisposing factors
dietary deficiency of calcium, for example in developing countries
prolonged breastfeeding
unsupplemented cow’s milk formula
lack of sunlight

Features
aching bones and joints
lower limb abnormalities:
in toddlers genu varum (bow legs)
in older children - genu valgum (knock knees)
‘rickety rosary’ - swelling at the costochondral junction
kyphoscoliosis
craniotabes - soft skull bones in early life
Harrison’s sulcus

Investigations
low vitamin D levels
reduced serum calcium - symptoms may results from hypocalcaemia
raised alkaline phosphatase

Management
oral vitamin D
Rickets (Vitamin D Deficiency)
 If calcium deficient rickets with vitamin D deficiency:
o Daily calcium AND
o Ergocalciferol (vit D2) / colecalciferol (vit D3)
 If pseudo-vitamin D deficiency (defect in 1-alpha hydroxylase)
o Calcitriol / alfacalcidol
 Phosphate salts are used in hypophosphataemic rickets
 Dietary: oily fish, egg yolk

Question 16

A 5-year-old boy has diffuse lower limb bone pain and tenderness. His past medical history and family history are mostly unknown, however, he is known to have been malnourished and is currently under the care of social services.

On examination, he is malnourished and pale, there is bossing of his forehead, bowing of his legs, and prominent kyphoscoliosis of his spine. When walking, he has a waddling gait. A growth chart is plotted and his weight is below the 2nd centile.

Given the likely diagnosis, what radiological feature may be seen?

Ballooning
Joint space narrowing
Joint widening
Osteolysis
Periarticular erosions

Answer 16

Joint widening

Rickets can present as widening of the wrist joints due to an excess of non-mineralized osteoid at the growth plate

Joint widening is correct. The patient has signs and symptoms consistent with rickets characterised by their forehead bossing, bowing of the legs and waddling gait, bone pain, and kyphoscoliosis of the spine. They are also malnourished and pale which can indicate that cause may be a dietary deficiency of vitamin D. This leads to inadequate mineralisation of developing bones leading to a widening of the joints due to an excess of non-mineralised osteoid at the growth plate.

Ballooning is incorrect. This is a type of cortical bone destruction affecting the inner bone cortex with new bone formation outside the cortex leading to an expansile, balloon-like appearance of the bone. This is associated with bone malignancies and is not seen in rickets.

Joint space narrowing is incorrect. This is associated with osteoarthritis and rheumatoid arthritis, either due to joint overuse or inflammation leading to a reduction in the cartilage lining the bones. These diagnoses would not explain the bone pain, forehead bossing, bowing of the legs, and waddling gait. This feature is not seen in rickets.

Osteolysis is incorrect. Dysfunctional bone remodelling can occur when osteoclast activity outweighs osteoblast activity leading to excessive bone breakdown, and this leads to osteolysis. This is associated with Paget’s disease of the bone, which would typically present with long bone pain in elderly patients.

Periarticular erosions is incorrect. These are seen in rheumatoid arthritis, where there is excessive bone resorption and inadequate bone formation around the affected joints. This would present with joint pain and stiffness that is worse in the morning and improves throughout the day. They are not seen in rickets.

Question 17

A four-year-old boy is brought in having been rescued, with his asylum-seeking parents, from a boat off the coast. The child is clearly malnourished, and his parents confirm, that due to conflict in their home country, he has spent most of his life hidden indoors and in shelters.

On skeletal examination the child has bossing of the forehead, bowing of his legs and significant kyphoscoliosis of the spine.

What is a recognised radiological feature of this child’s condition?

Ballooning
Osteolysis
Periarticular erosions
Sclerotic rims
Widening of joints

Answer 17

Widening of joints

Rickets can present as widening of the wrist joints due to an excess of non-mineralized osteoid at the growth plate

This child has presented with features in keeping with the bone disease Rickets. It is most often due to vitamin D deficiency, usually due to poor dietary intake and/or reduced sun exposure. This results inadequately mineralised developing/growing bones. A recognised radiological feature of the condition is widening of joints, specifically of the wrists, due to an excess of non-mineralised osteoid at the growth plate.

Ballooning is associated with rare bone malignancies and is a result of cortical destruction. In ballooning, there is an expansive, balloon-like appearance, normally of the long bone due to destruction of the endosteal cortical bone and the addition of newly formed bone on the outer surface occurring at the same rate. This feature is not seen in Rickets disease.

Osteolysis is associated with Paget’s bone disease where dysregulated bone remodelling occurs with excessive bone breakdown and subsequent disorganised new formation. The initial significant bone resorption is seen radiological as lytic lesions, a process known as osteolysis. This marked bone destruction is not seen in Rickets.

Periarticular erosions are a late sign in arthritic conditions, such as rheumatoid arthritis (RA), where there is excessive bone resorption and inadequate bone formation around affected joints. Again this radiological sign is not associated with Rickets.

Sclerotic rims or overhanging edge is due to bone erosion and therefore is seen in the later stages of conditions such as gout and RA and not in the bone demineralisation condition of Rickets.