2. lack of vitamin D, calcium, or
phosphate, which leads to
softening and weakening of the bones.
Defective mineralization of bone matrix –
excessive unmineralised osteoid
3. Vitamin D helps the body properly control
calcium and phosphate levels in the body.
When the body is deficient in vitamin D, it is
unable to properly control calcium and
phosphate levels
calcium and phosphorous are found in milk and
green vegetables.
4. Defective Vitamin D metabolism –
lowering of calcitriol -
intestinal malabsorption of calcium -
reduction of serum calcium –
Parathyroid stimulation –
normalised S.calcium at the expense of
reduced S.Phosphate
6. ultraviolet rays
7-Dihydrocholesterol
Cholecalciferol (Vitamin D3)- in dermis
Vit D2 absorbed thru small intestine
Transport in serum- binds with X-globulin
25-Hydroxylation in Liver
1,25- Dihyroxylation in Kidney – active form
8. Decrease in effect & amount of Sunlight
Bread/Chapathi rich in Phytate bind dietary
calcium – reduced absorption
Infants who are exclusively breastfed may
develop vitamin D deficiency.
Poor Dietary intake of Ca & Vit D
Malabsorption disorders – Coeliac d/s, hepatic
osteodystrophy, lactose intolerance
9. Renal – Renal osteodystrophy, Nephrectomy,
renal failure, hypoparathyroidism,
X-linked hypophosphatemia/Vit D resistant
rickets
Vitamin dependant Type I (Inability to hydroxylate)
Vitamin dependant Type II (Receptor insensitivity)
Anticonvulsant therapy( 25OH in liver)
10. Failure of deposition of Ca along mature
cartilage cell columns
Disorderly invasion of cartilage by blood
vessels
Lack of reabsorption at the zone of
provisional calcification
Increased thickness of epiphyseal plate
11. Abundant osteoid with
Defective mineralization
No resorption of uncalcified osteoid by
osteoclasts
Normal osteoblast – laid irregularly
Abnormal arrangement of collagen bundles in
compact bone
12. Long bones bent when child starts
crawling/walking
22. Bone pain or tenderness
Arms Legs Spine Pelvis
Skeletal deformities
o Bowlegs
o pigeon chest
o rachitic rosary
o Frontal bossing
o Spine deformities (spine curves
abnormally, including scoliosis or
kyphosis )
o Pelvic deformities
23. Increased tendency toward bone
fractures
Dental deformities
o Delayed formation of teeth
o Defects in the structure of teeth, holes in
the enamel
o Increased incidence of cavities in the
teeth ( dental caries )
o Decreased muscle tone (loss of muscle
strength)
Muscle cramps
Impaired growth
Short stature
26. Dense shadow
Dense line at the end of metaphysis-
deposition of Ca
Stage of repair
27. Increase in breadth of metaphysis
Clearly defined bone
Normal content of Ca salts
Bone completely repaired
28.
29. Serum Ca low or normal.
o Tetany -prolonged muscle spasm.
o Chvostek's sign may be positive (a spasm of
facial muscles occurs when the facial nerve
is tapped)
S.Phosphorus may be low.
S.ALP may be high.
ABG may reveal metabolic acidosis
Urinary Ca may be low .
30. 24-hydroxylase assay – for vitamin D
dependency rickets
Serum 25-OH vitamin levels
A bone biopsy is rarely performed but will
confirm rickets.
34. Dietary sources of vitamin D include fish, liver,
milk and cheese.
Exposure to moderate amounts of sunlight is
encouraged.
Reduce cereal containing phytates
Supplemention of Calcium and
Vitamin D – 3000 i.u./day
36. Control of movements – reduced pressure upon
limbs
(soft bones easily bent by pressure / muscle
strain)
Positioning or bracing with ‘rickets’ splints may be
used.
37. Correction by splinting
In young children below 4 yrs
Useful in lower limbs
Continuous supervision needed to prevent
sores
38. Correction by osteotomy
When deformity is near a joint
At least stage 3 in radiograph
39. Chronic skeletal pain
Skeletal deformities
Skeletal fractures, may occur without cause
40. Rickets of prematurity
Very premature infants at risk
Risk factors- hepatobiliary d/s, TPN,
Diuretic therapy, chest percussion therapy
Pathologic # in NICU
Readily heal with treatment
41. Antiepileptic medications
Induce microsomal P-450 enz
Decreased Vit D
Should be suspected in neurologic patients
having seizures
Start having frequent #
42. Familial hypophosphatemic rickets
X-linked dominant (MC)- Mutn in PEX gene
Aut dominant 12p13 – phosphatonins – fgf
23 – cause phosphaturia
Aut recessive
43. Renal tubule unable to retain PO4
End organ insensitivity to vit D (AR)
Kidney unable to perform 2nd hydroxylation
Renal tubular acidosis (kidney excretes fixed
base and wastes bicarbonate)
Ca ppt – renal calcinosis
44. Older age
Delayed walking, angular deformities
Systemic manifestn – irritability and apathy
minimal
Treatment – Oral Phosphorus , Vit D
(Compl – nephrocalcinosis)
Growth hormone – increased height,
increased PO4, reduced Nephrocalcinosis
45. Surgery not efficacious – multilevel osteotomy
to correct mechanical axis
Recurrent deformity common
Surgery when - gait compromised/severe
pain
46. Oncogenic hypophosphatemic
osteomalacia
Asso with Neurofibromatosis, fibrous
dysplasia
Osteoblastoma, hemangiopericytoma of
bone, skin tumors
(disrupts renal tubular abs of po4)
Secrete phosphatonins
Resolve with excision of tumor
47. C/C pyelonephritis
Congenital Abnormalities
Polycystic kidney d/s
Secondary hyperparathyroidism
Leads to actvn of osteoclast and resorption of
bone (high turn over d/s)
48. Glomerulus unable to excrete Phosphorus
Vit D prodn reduced
Ca abs from S.Intestine reduced
PTH triggered
Increased S.Ca – bone demineralization
Precipitate in cornea, skin, blood vessels
49. C/F similar to Nutritional.
Angular deformity, SCFE, AVN
Radiography – cuppping of physis not
present
Subperiosteal resorption in phalanges, MC
and ulna (feature of Hyperparathyroidism)
Osteosclerosis of skull, rugger jersey spine
Lytic areas in long bones (Brown tumors)
Treat underlying d/s- Ca, Vit D, growth
hormone, osteotomy, Ilizarov
50. Ca Normal or low in all
Phosphate is reduced in all except Renal
Osteodystrophy
ALP and PTH high in all
25 OH Vit D N or high in all except
nutritional (decreased)
1,25 (OH)2 N or low in all except Vit D
dependent typeII (receptor insensitivity)
51. Maintain an adequate intake of calcium,
phosphorus, and vitamin D.
This may require dietary supplements in
people who have gastrointestinal or other
disorders
Renal causes of vitamin D should be treated
promptly.
52. Levels of calcium and phosphorus should be
monitored regularly in people who have renal
disorders .
Genetic counseling may help people with a family
history of inherited disorders that can cause
rickets.