Approach To Child with Rickets Dr.Sandeep C Agrawal Agrasen Hospital Gondia india www.agrasenortho.com
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CALCIUM,VITAMIN D,OSTEOPOROSIS,DIET, METABOLIC BONE DISEASE,HYPERPARATHYROIDISM,RENALOSTEODYSTROPHY,RICKETS,BONEMETABOLISM,Vitamin D Resistant Rickets Type 1 & 2,Fanconi anemia,Renal tubular acidosis,Familial Hypophosphatemia Rickets,Renal Rickets,Hepatic Rickets,Malabsorption Rickets,Hypophosphatasia,Malabsorption Rickets,Metaphyseal Dysplasia,APPROACH TO CHILD WITH RICKETS,Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com.
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Approach To Child with Rickets Dr.Sandeep C Agrawal Agrasen Hospital Gondia india www.agrasenortho.com
- 1. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com Dr.Sandeep Agrawal Consultant Orthopedic Surgeon MS,DNB Agrasen Hospital Gondia Maharashtra India drsandeep123@gmail.com ! www.agrasenortho.com ! 09960122234 Practical approach to Rickets
- 2. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com Practical approach to child with Rickets. Level 1. Is it true Rickets or rickets like states ? ! Do preliminary investigations – Serum calcium, phosphate, Serum Alk P04ase(SAP) ! Have a close look at the x rays ! Consider the following conditions ! ! Hypophosphatasia Metaphyseal dysplasia !
- 3. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com Level 1 – is it True Rickets or rickets like states ? Features ! ! Radiological signs similar to rickets. But growth plate are not wide with differential involvement of bones in a joint.! Eg. Femur shows changes but tibia is normal.! ! Levels of serum Ca, P and SAP normal.! ! Diagnosis! Metaphysial dysplasia
- 4. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com Features .---- ! Clinical signs or rickets are present but x rays show tongue like radiolucency projecting from growth plate into metaphysis. ! In rickets growth plate is uniformly wide. ! SAP levels are low but S. ca, P Levels are normal. ! ! Diagnosis Hypophasphatasia
- 5. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com Level 2 – is it nutritional or non nutritional ?! ! Look for clues in history or examination:! ! Prematurity Neonatal cholestasis Anticonvulsant therapy Chronic renal disease
- 6. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com Level 2: Is it nutritional or non nutritional? Useful clues 1.Jaundice - Hepatobiliary disease Metabolic disorders ! 2.Cataract - Galactosemia, Wilson’s ! ! 3.Positive family history - Metabolic disease, RTA ! ! 4.Mental retardation, seizures - Galactosemia ! ! 5. Drug induced rickets in primary CNS problem ! ! 6.Alopecia - VDDR type 2.
- 7. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com Level 2.. Is it nutritional or non nutritional? In the absence of clues –! Presume and treat it as vit D deficiency rickets.! Give vitamin D2 (inj. arachitol) 600000 units 2 doses at two to three weeks interval . Improvement occurs in nutritional rickets.! ! ! Healing is indicated by the presence of provisional zone of calcification.! ! Non healing favours a non nutritional cause.
- 8. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com Level 2.. Is it nutritional or non nutritional? Features of non nutritional causes:! ! Presentation before six months or after two years of age! Associated failure to thrive! Positive family history! Obvious clues mentioned earlier! Failure of vitamin D therapy
- 9. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com Level 3. if it is non nutritional and lack any obvious clues it could be either due to GI or Renal cause: Features ….! ! Recurrent diarrhea, oily stools. Recurrent abdominal pain and distension. ! Anemia, hypoproteinemia. ! Multiple vitamin and mineral deficiencies. ! Diagonosis ! Malabsorption with rickets.
- 10. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com If it is non nutritional and lack any obvious clues it could be either due to GI or renal cause Features …! ! Hepatobiliary findings:! ! Raised serum billirubin low serum albumin prolonged prothrombin time. ! Diagnosis ! Hepatic rickets
- 11. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com Level 3.. If it is non nutritional and lack any obvious clues it could be either due to GI or renal cause Features…! Failure to thrive Recurrent vomiting lethargy Acidotic breathing. Hypertension, anemia with or without edema. ! ! Positive findings in urine analysis. Abnormalities in electrolytes, Blood urea and creatinine. Renal abnormalities in ultrasound abdomen. ! Diagnosis! ! Renal rickets
- 12. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com Level 4.. If it is rickets due to Renal causes what is the underlying renal problem that led to rickets.? Depends on the clinical features of chronic renal failure and on laboratory investigations.! ! Do urine analysis! Blood for electrolytes, urea and creatinine.! Blood gas analysis.! Ultrasonography abdomen.
- 13. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com Level 3.. If it is non nutritional and lack any obvious clues it could be either due to GI or renal cause Features…! ! Vomiting , lethargy, growth retardation! Hypertension, anemia, with or without edema.! Features of obstructive uropathy.! Raised blood urea, creatinine.. S. potassium may be high.! Abnormalities in USG, MCU and DMSA scan.! ! Diagnosis ! Chronic renal failure - renal osteodystrophy.
- 14. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com Features…! ! Recurrent vomiting, diarrhoea with acidotic breathing.! Positive family history.! Metabolic acidosis with normal anion gap, hypokalemia, and raised serum chloride! Normal blood urea and serum creatinine.! No proteinuria or glycosuria.! ! Diagnosis ! Renal tubular acidosis
- 15. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com Features….! Severe form of rickets with stunting and deformity.! Features mentioned in RTA.! Proteinura, glycosuria present.! Normal or slightly increased B.urea and S.creatinine.! Features of underlying causes such as cystinosis.! ! Diagnosis! Fanconi syndrome
- 16. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com Features…! ! Lower limb deformity, stunted growth.! Often with family history.! Frequent dental abscess and early decay.! Low serum phosphate and low TRP.! ! Diagnosis ! Familial hypophosphataemic rickets(FHR)
- 17. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com Level 5.. Child with rickets, no clues so far, what else? Features…! Often presenting in early infancy! Hypocalcemic tetany! ! Improvement with vitamin D therapy and recurrence of symptoms on discontinuation.! ! Diagnosis ! Vitamin D dependent rickets type1
- 18. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com Features…! ! Alopecia with or without any response to any form of vitamin D! High serum levels of 1,25 dihydroxy vitamin D! ! Diagnosis ! Vitamin D dependent rickets type2 ! 1,25(OH)2 vit D level is high in contrast to VDDR type 1 where it is low.
- 19. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com Make the Years Count Lincoln didn’t live to a very old age, but the “life in his years” made a profound impact on the world. Are you making your years count? Are you changing the world? You’re capable of it; if you’re able to read and understand these words, then you have the ability to make a profound impact, and that’s not just meaningless rhetoric, it’s a very real reality, but will you grasp it, will you believe it and make it “your” reality. THANKS