eMedicine Specialties > Radiology > Pediatrics

Rickets: Imaging

Author: Rick R van Rijn, MD, PhD, Pediatric Radiologist, Department of Radiology, Academic Medical Center Amsterdam
Coauthor(s): Kieran McHugh, MBBCh, Honorary Lecturer, The Institute of Child Health; Consultant Pediatric Radiologist, Department of Radiology, Great Ormond Street Hospital for Children, London, UK
Contributor Information and Disclosures

Updated: Mar 18, 2009

Radiography

Anteroposterior and lateral radiographs of the wrist of an 8-year-old boy with rickets demonstrates cupping and fraying of the metaphyseal region.

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Anteroposterior and lateral radiographs of the wrist of an 8-year-old boy with rickets demonstrates cupping and fraying of the metaphyseal region.

Radiographs of the knee of a 3.6-year-old girl with hypophosphatemia depict severe fraying of the metaphysis.

[ CLOSE WINDOW ]

Radiographs of the knee of a 3.6-year-old girl with hypophosphatemia depict severe fraying of the metaphysis.

Radiograph in a 4-year-old girl with rickets depicts bowing of the legs caused by loading.

[ CLOSE WINDOW ]

Radiograph in a 4-year-old girl with rickets depicts bowing of the legs caused by loading.

Radiograph in a 4-year-old girl with rickets, focused on the knees. Image depicts the development of knock-knees.

[ CLOSE WINDOW ]

Radiograph in a 4-year-old girl with rickets, focused on the knees. Image depicts the development of knock-knees.

Radiograph of the proximal humerus in a 2.5-year-old girl who had a peripheral neuroectodermal tumor of the right brachial plexus. After treatment with ifosfamide, the patient developed rickets of the proximal femur. In this case, metastasis should be incorporated into the differential diagnosis.

[ CLOSE WINDOW ]

Radiograph of the proximal humerus in a 2.5-year-old girl who had a peripheral neuroectodermal tumor of the right brachial plexus. After treatment with ifosfamide, the patient developed rickets of the proximal femur. In this case, metastasis should be incorporated into the differential diagnosis.

Radiograph of the knees of an 11-year-old boy with treated vitamin D–resistant rickets. Image demonstrates bilateral multiple growth arrest lines and underdevelopment of the medial aspect of both the tibial plateau and the femoral condyle.

[ CLOSE WINDOW ]

Radiograph of the knees of an 11-year-old boy with treated vitamin D–resistant rickets. Image demonstrates bilateral multiple growth arrest lines and underdevelopment of the medial aspect of both the tibial plateau and the femoral condyle.

Radiograph of a leg with the patient in a standing position demonstrates knock-knees. The patient is an 11-year-old boy with treated vitamin D–resistant rickets.

[ CLOSE WINDOW ]

Radiograph of a leg with the patient in a standing position demonstrates knock-knees. The patient is an 11-year-old boy with treated vitamin D–resistant rickets.

Findings

Plain radiograph findings include the following:

Widening and cupping of the metaphyseal regions (see Image 1)
Fraying of the metaphysis (see Images 2-3)
Craniotabes
Bowing of long bones (see Images 4-6)
Development of knock-knees, or genu valgum (see Images 5-7)
Development of scoliosis
Impression of the sacrum and femora into the pelvis, leading to a triradiate configuration of the pelvis
In healing rickets, the zones of provisional calcification become denser than the diaphysis. In addition, cupping of the metaphysis may become more apparent.

A useful mnemonic for remembering the findings of rickets is as follows:

Reaction of the periosteum (may occur)
Indistinct cortex
Coarse trabeculation
Knees, wrists, and ankles affected predominantly
Epiphyseal plates, widened and irregular
Tremendous metaphysis (cupping, fraying, splaying)
Spur (metaphyseal)

Degree of Confidence

In more advanced stages of rickets, radiographic changes are pathognomonic; however, the underlying cause needs to be established using clinical and biochemical assessments.

False Positives/Negatives

False-negative findings can occur in the early phase of disease.

More on Rickets

Imaging: Rickets

Yasuda T. [Rickets]. Clin Calcium. Jan 2009;19(1):109-16. [Medline].
Xiang W. [Review of progresses in prevention and treatment of vitamin D deficiency and rickets in childhood]. Zhonghua Er Ke Za Zhi. Mar 2008;46(3):195-7. [Medline].
Wagner CL, Greer FR. Prevention of rickets and vitamin D deficiency in infants, children, and adolescents. Pediatrics. Nov 2008;122(5):1142-52. [Medline].
Backstrom MC, Kuusala AL, Maki R. Metabolic bone disease of prematurity. Ann Med. Aug 1996;28(4):275-282.
Welch TR, Bergstrom WH, Tsang RC. Vitamin D–deficient rickets: the reemergence of a once-conquered disease. J Pediatr. Aug 2000;137(2):143-5. [Medline].
Tomashek KM, Nesby S, Scanlon KS, et al. Nutritional rickets in Georgia. Pediatrics. Apr 2001;107(4):E45. [Medline].
Prentice A. Vitamin D deficiency: a global perspective. Nutr Rev. Oct 2008;66(10 Suppl 2):S153-64. [Medline].
Thacher TD, Fischer PR, Strand MA. Nutritional rickets around the world: causes and future directions. Ann Trop Paediatr 2006 Mar;26(1):1-16.
Dabezies EJ, Warren PD. Fractures in very low birth weight infants with rickets. Clin Orthop. Feb 1997;(335):233-9. [Medline].
Wauters IM, van Soesbergen RM. [Disease caused by lack of sunlight: rickets and osteomalacia]. Ned Tijdschr Geneeskd. Mar 20 1999;143(12):593-7. [Medline].
Mosekilde L. Vitamin D requirement and setting recommendation levels: long-term perspectives. Nutr Rev. Oct 2008;66(10 Suppl 2):S170-7. [Medline].
Allgrove J. Is nutritional rickets returning?. Arch Dis Child. Aug 2004;89(8):699-701. [Full Text].
Arthur A. Rickets in the welfare state. N Z Med J. Oct 27 2000;113(1120):452. [Medline].
Behrman RE, Kliegman RM, Jensen HB, et al. Nelson Textbook of Pediatrics. 17th ed. Philadelphia, Pa: WB Saunders Co;2004.
Brunvand L, Brunvatne R. [Health problems among immigrant children in Norway]. Tidsskr Nor Laegeforen. Feb 28 2001;121(6):715-8. [Medline].
CDC. Severe malnutrition among young children—Georgia, January 1997-June 1999. MMWR Morb Mortal Wkly Rep. Mar 30 2001;50(12):224-7.
Do TT. Clinical and radiographic evaluation of bowlegs. Curr Opin Pediatr. Feb 2001;13(1):42-6. [Medline].
Kottamasu SR. Metabolic Bone Diseases. In: Kuhn JP, Slovis TL, Haller JO, eds. Caffey's Pediatric Diagnostic Imaging. 10th ed. Philadelphia, Pa: Mosby; 2004: 2242-2253.
Krane SM, Hollick MF. Metabolic bone disease. In: Wilson JD, et al, eds. Harrison's Principles of Internal Medicine. 12th edition. New York, NY: McGraw-Hill;1991:1921-31.
Pal BR, Shaw NJ. Rickets resurgence in the United Kingdom: improving antenatal management in Asians. J Pediatr. Aug 2001;139(2):337-8. [Medline].
Pitt MJ. Rickets and osteomalacia. In: Resnick D, Bralow L, eds. Bone and Joint Imaging. 2nd ed. Philadelphia, Pa: WB Saunders Co;1996:511-24.
Renton P. Radiology of rickets, osteomalacia and hyperparathyroidism. Hosp Med. May 1998;59(5):399-403. [Medline].
Rowe PM. Why is rickets resurgent in the USA?. Lancet. Apr 7 2001;357(9262):1100. [Medline].

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Keywords

rickets, English disease, osteomalacia, rachitis, vitamin D deficiency, abnormal vitamin D metabolism, scoliosis, craniotabes, bowing of long bones, knock-knees, genu valgum, triradiate pelvis, metaphyseal cupping, metaphyseal widening, metaphyseal spur, widened epiphyseal plates, metaphyseal fraying, metaphyseal splaying, rickets rosary, saber shin deformity

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Contributor Information and Disclosures

Author

Rick R van Rijn, MD, PhD, Pediatric Radiologist, Department of Radiology, Academic Medical Center Amsterdam
Rick R van Rijn, MD, PhD is a member of the following medical societies: European Society of Paediatric Radiology, European Society of Radiology, and Nederlandse Vereniging voor Radiologie
Disclosure: Nothing to disclose.

Coauthor(s)

Kieran McHugh, MBBCh, Honorary Lecturer, The Institute of Child Health; Consultant Pediatric Radiologist, Department of Radiology, Great Ormond Street Hospital for Children, London, UK
Kieran McHugh, MBBCh is a member of the following medical societies: American Roentgen Ray Society and Royal College of Radiologists
Disclosure: Nothing to disclose.

Medical Editor

Beverly P Wood, MD, PhD, Professor Emerita, Departments of Radiology and Pediatrics, Division of Medical Education, Keck School of Medicine, University of Southern California; Professor of Clinical Radiology, Loma Linda University School of Medicine
Beverly P Wood, MD, PhD is a member of the following medical societies: American Academy of Pediatrics, American Association for Women Radiologists, American College of Radiology, American Institute of Ultrasound in Medicine, American Medical Association, American Roentgen Ray Society, Association of University Radiologists, Radiological Society of North America, and Society for Pediatric Radiology
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

David A Stringer, BSc, MBBS, FRCR, FRCPC, Professor, National University of Singapore; Head, Diagnostic Imaging, KK Women's and Children's Hospital, Singapore
David A Stringer, BSc, MBBS, FRCR, FRCPC is a member of the following medical societies: British Columbia Medical Association, Canadian Association of Radiologists, European Society of Paediatric Radiology, Ontario Medical Association, Radiological Society of North America, Royal College of Physicians and Surgeons of Canada, Royal College of Radiologists, and Society for Pediatric Radiology
Disclosure: Sirius d'innovation None Board membership

CME Editor

Robert M Krasny, MD, Consulting Staff, Department of Radiology, The Angeles Clinic and Research Institute
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

Felix S Chew, MD, MBA, EdM, Professor, Department of Radiology, Vice Chairman for Radiology Informatics, Section Head of Musculoskeletal Radiology, University of Washington
Felix S Chew, MD, MBA, EdM is a member of the following medical societies: American Roentgen Ray Society, Association of University Radiologists, and Radiological Society of North America
Disclosure: Nothing to disclose.

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eMedicine Specialties > Radiology > Pediatrics

Rickets: Imaging

Radiography

Anteroposterior and lateral radiographs of the wrist of an 8-year-old boy with rickets demonstrates cupping and fraying of the metaphyseal region.

Anteroposterior and lateral radiographs of the wrist of an 8-year-old boy with rickets demonstrates cupping and fraying of the metaphyseal region.

Radiographs of the knee of a 3.6-year-old girl with hypophosphatemia depict severe fraying of the metaphysis.

Radiographs of the knee of a 3.6-year-old girl with hypophosphatemia depict severe fraying of the metaphysis.

Radiograph in a 4-year-old girl with rickets depicts bowing of the legs caused by loading.

Radiograph in a 4-year-old girl with rickets depicts bowing of the legs caused by loading.

Radiograph in a 4-year-old girl with rickets, focused on the knees. Image depicts the development of knock-knees.

Radiograph in a 4-year-old girl with rickets, focused on the knees. Image depicts the development of knock-knees.

Radiograph of the proximal humerus in a 2.5-year-old girl who had a peripheral neuroectodermal tumor of the right brachial plexus. After treatment with ifosfamide, the patient developed rickets of the proximal femur. In this case, metastasis should be incorporated into the differential diagnosis.

Radiograph of the proximal humerus in a 2.5-year-old girl who had a peripheral neuroectodermal tumor of the right brachial plexus. After treatment with ifosfamide, the patient developed rickets of the proximal femur. In this case, metastasis should be incorporated into the differential diagnosis.

Radiograph of the knees of an 11-year-old boy with treated vitamin D–resistant rickets. Image demonstrates bilateral multiple growth arrest lines and underdevelopment of the medial aspect of both the tibial plateau and the femoral condyle.

Radiograph of the knees of an 11-year-old boy with treated vitamin D–resistant rickets. Image demonstrates bilateral multiple growth arrest lines and underdevelopment of the medial aspect of both the tibial plateau and the femoral condyle.

Radiograph of a leg with the patient in a standing position demonstrates knock-knees. The patient is an 11-year-old boy with treated vitamin D–resistant rickets.

Radiograph of a leg with the patient in a standing position demonstrates knock-knees. The patient is an 11-year-old boy with treated vitamin D–resistant rickets.

Findings

Degree of Confidence

False Positives/Negatives

More on Rickets

References

Further Reading

Keywords

Contributor Information and Disclosures

Author

Coauthor(s)

Medical Editor

Pharmacy Editor

Managing Editor

CME Editor

Chief Editor