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Patient Story

A 2-year-old boy is brought to the pediatrician by his mother, who reports that the boy appears more irritable lately and does not seem to be growing. After further questioning, the mother mentions that her child has also complained of leg pain and a “waddling” gait. On exam, the boy has widening of the wrists and bowing of his legs and prominence of the costochondral junctions (rachitic rosary; Figures 198-1 and 198-2). The pediatrician asks about the child’s diet, and the mother reveals that the patient is a very picky eater and drinks only fruit juice that is not fortified with vitamin D. The pediatrician is concerned about rickets and orders a serum alkaline phosphatase, which is elevated, and vitamin D level (25-OH Vitamin D), which is low. X-ray of the tibia and femur demonstrated widening of the growth plate and metaphysis (Figure 198-3). The pediatrician prescribes vitamin D and calcium supplementation for the child. After 3 months of supplementation, the boy’s symptoms have resolved and repeat x-ray showed a dense zone of calcification at the metaphysis with improvement in the widened growth plate.

FIGURE 198-1

Widening of the wrists, bowed legs, bowing of the forearms, and frontal bossing in a young child with nutritional rickets. (Used with permission from Cleveland Clinic Children’s Hospital Photo Files.)

FIGURE 198-2

Prominence of the costochondral junction (rachitic rosary) in the same child as in Figure 198-1. (Used with permission from Cleveland Clinic Children’s Hospital Photo Files.)

FIGURE 198-3

Cupping and fraying of the metaphyses and bowing of the tibia and femur on (A) bilateral and (B) unilateral views. (Used with permission from Cleveland Clinic Children’s Hospital Photo Files.)


  • Rickets is a defect in bone mineralization that occurs in children prior to epiphyseal fusion, resulting in widening of the growth plates, bone pain, decreased strength of bone, bone deformities, and signs of hypocalcemia.13 This condition is primarily due to nutritional deficiency, specifically vitamin D deficiency, but can also occur with calcium or phosphorus deficiency. There are also hereditary and secondary (renal losses of calcium and phosphate) causes of rickets. Management of rickets depends on the specific etiology. Nutritional deficiencies can be treated with supplementation.


Osteomalacia in children, Osteomalacia (Rickets in adults).


  • Nutritional rickets in the US is relatively uncommon; in case reports published between 1986 to 2003, there were 166 cases of documented rickets.4

  • The prevalence of hypovitaminosis D in the US ranges from 1 to 78 percent with breastfed ...

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