Rickets: Clinical Features

• Head
  • Skull - Craniotabes may occur, in which the bones of the skull soften and flattening of the posterior skull can be seen. These effects may be transient or permanent. Another feature is the prominence of the frontal bones and the major foramen, resulting in frontal bossing or a prominent, sometimes square, forehead (caput quadratum).
  • Teeth - Teeth may erupt later than normal because of undermineralization. Enamel can be of poor quality, resulting in caries.
• Thorax
  • Rachitic rosary - The enlarged ends of the ribs, resembling beads, can be palpable and visible at the costochondral junction. As a result, the sternum can become more prominent, leading to a pigeon breast or pectus carinatum appearance.
  • Harrison groove - The groove is a semicoronal impression over the abdomen at the level of the insertion of the diaphragm, which can be seen in rickets.
• Spine - A mild to more pronounced scoliosis may be seen as a result of rickets.
• Pelvis - A prominent promontory can be found, and the anteroposterior (AP) diameter of the pelvis can shrink as a result of scoliosis. If this persists in girls, it can cause complications later in life during childbirth.
• Extremities
  • Arms
    • Bowing of the long bones, as a reaction to greenstick fractures, results from concurrent osteomalacia.
    • Thickening of the wrist at the level of the epiphysis is not visible radiographically, since the lesion consists of cartilage, although fraying and cupping of the metaphysis is evident.
  • Legs
    • Bowing of the long bones (genu varum)as a result of weight bearing is typical.
    • Anterior bowing of the tibia (saber shin deformity) may occur.
    • Development of knock-knees (genu valgum) may occur because of displacement of the growth plates during active disease.
    • Thickening at the level of the ankle may occur, identical to the process in the wrist.
• Ligaments and muscles - Laxity in the ligaments is increased, and muscle tone is decreased. This combination leads to a delay in motor development.

Rickets : X Rays

Xray: Bowing of legs




Cupping of epiphysis
Splaying of Metaphysis

11 Categories Of Rickets

Because rickets results from a metabolic disturbance, the underlying disease should be diagnosed. The causes of rickets can be classified into 11 main categories:

• Vitamin D deficiency
  • Dietary deficiency
  • Deficient endogenous synthesis
• Gastrointestinal tract disorders
  • Small intestine diseases with malabsorption
  • Partial or total gastrectomy
  • Hepatobiliary disease
  • Chronic pancreatic insufficiency
• Disorders of vitamin D metabolism
  • Hereditary - Pseudovitamin D deficiency or vitamin D dependency (types I and II)
  • Acquired
    • Use of anticonvulsants
    • Chronic renal failure
• Acidosis
  • Distal renal tubular acidosis (classic or type I)
  • Secondary forms of renal acidosis
  • Ureterosigmoidostomy
  • Drug-induced disease
    • Chronic acetazolamine ingestion
    • Chronic ammonium chloride ingestion
• Chronic renal failure
• Phosphate depletion
  • Dietary - Low phosphate intake plus ingestion of nonabsorbable antacids
    • Hereditary - X-linked hypophosphatemic rickets or adult-onset vitamin D–resistant hypophosphatemic osteomalacia
    • Acquired - Sporadic hypophosphatemic osteomalacia (phosphate diabetes), tumor-associated (oncogenous) rickets, osteomalacia, neurofibromatosis, and fibrous dysplasia
• Generalized renal tube disorders
  • Primary renal tube disorders
  • Renal tube disorders associated with systemic metabolic abnormality
    • Cystinosis
    • Glycogenosis
    • Lowe syndrome
  • Systemic disorder with associated renal disease
    • Hereditary - Inborn errors (Wilson disease, tyrosinemia) and neurofibromatosis
    • Acquired - Multiple myeloma, nephrotic syndrome, and kidney transplantation
    • Intoxication-related - Cadmium, lead, outdated tetracycline
• Primary mineralization defects
  • Hereditary
  • Acquired
    • Diphosphonate treatment
    • Fluoride treatment
• States of rapid bone formation with or without a relative defect in bone resorption
  • Postoperative hyperparathyroidism with osteitis fibrosa cystica
  • Osteopetrosis
• Defective matrix synthesis - Fibrogenesis imperfecta ossium
• Miscellaneous
  • Magnesium-dependent conditions
  • Axial osteomalacia
  • Parenteral alimentation
  • Aluminum intoxication
  • Isofosfamide treatment