1. DR. SABYASACHI BARDHAN
RICKETS & OSTEOMALACIA

2. DEFINITION
Interruption of orderly mineralisation and
development of growth plate due to disorder in
Ca, P & Vit D metablism

3. TYPES
 Vit D defficiency rickets: Nutritional, GI
 Vit D dependant rickets(VDDR)
I: 1 alpha hydroxylase deff : Vit D3 not formed
II: End organ resistance
 Vit D resistant rickets (VDRR)
RTA: Prox & distal, Fanconi, Oncogenic, XLHR
Phosphorus loss due to lack of absorption and
increased secreation
 Renal osteodystrophy
Renal parenchymal disorder (CKD)
Phosphorus retention, Reduced Vit D3 production

5. NORMAL PHYSIOLOGY
 Bone consists of protein matrix –osteoid
 Mineral phase-calcium and phosphorus.
 Intramembranous ossification-flat bones
mesenchymal cells differentiate into osteoblasts
 Enchondral ossification –long tubular bones
 Growing cartilage at the epiphyseal plates is
mineralized and resorbed and replaced by
osteoid matrix which undergoes mineralization to
create bone.
 IN RICKETS MINERALISATION IS INHIBITED
AT THE ZONE OF PROVISIONAL
CALCIFICATION

6. C/F
•Irritability , profuse
sweating while asleep,
hypotonia,frequent
respiratory infections.,
Failure to thrive, Fits,
tetany.
•Delay in walking
•Frontal bossing (due to
excess osteoid),
Craniotabes ,Delayed
closure of anterior
fontanel, delayed
dentition
• Rachitic Rosery
Harrison’s sulcus,
Pigeon chest deformity
•Widening of wrists
and ankles ,Bending of

7. RADIOLOGY
•Illdefined epiphysis
•Increased thickness
of physis
•Metaphyseal
broadening/splaying
•Cupping
•Fraying
•Thin cortices

8.  LITMUS BLUE TEST:
Urinary ph low in RTA
 SULKOWITCH TEST:
(Glacial acetic acid + Oxalic acid + Ammonium
oxalate)
+ Distilled water + Equal vol urine -> calcium ppt
Weigh the calcium, reflects blood Calcium level

9. BIOCHEMICAL PROFILE
Ca P PTH ALP 25(OH)
Vit D
Vit D
Defficienc
y
N/Low N/Low Increase
d
Increase
d
Low Ur P-
low
Vit D
Dependa
nt
Low Low Increase
d
Increase
d
Normal
Vit D
resistant
N/Low Low Normal Increase
d
D3 –N
Ur P-
High
Renal
Osteodyst
rophy
N/Low Increase
d
Increase
d
Increase
d
Normal D3- low

10. MEDICAL MANAGEMENT
TYPES TREATMENT
Vit D deff 600000 IU/15000mcg IM/ 0.5 -2 mcg calcitriol/day
orally + 500 mg Ca
VDDR I 2-3mcg calcitriol / day orally + Ca
supplementation
VDDR II Poor prognosis
30 mcg calcitriol /day + Ca + Dihydrotachysterol
VDRR 2-3 mcg calcitriol/ day orally + Ca+
NaH2PO4/Na2HPO4
Correction of fluid electrolyte imbalance,
nutritional supplementation
Renal Osteodystrophy 1-2 mcg calcitriol/ day orally + Ca
Dialysis

11. Surgery is indicated for residual unacceptable
deformities
 Hemiepiphysiodesis
 Osteotomy

12. HEALING RICKETS
 Zone of provisional
calcification becomes
denser
 Epiphysis well defined
 Width of physis
decreases

13. OSTEOMALACIA
 Vit D defficiency in adults (<20ng/ml; 21-29:Insufficiency)
 Aches and pains, muscle weakness loss of height, stress #s.
 Nutritional, GI disorder, Drugs (phenytoin, Phenobarbitone), Renal
osteodystrophy
 X ray: Osteopoenia, coarse trabeculae, Looser’s zone
 Vit D supplementation regimen
50,000 IU of vitamin D2 or D3 once weekly for 8 weeks or
6000 IU/day of vitamin D2 or D3 for 8 weeks
When the serum 25(OH)D level exceeds 30 ng/mL, provide
maintenance treatment of 1500-2000 IU/day

14. THANK
YOU