Rickets Imaging
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Vitamin D deficiency results in rickets in children with growing bones and causes osteomalacia in adults with completed growth and closed growth plates. By definition, rickets is found only in children before closure of the growth plates, while osteomalacia occurs in persons of any age. Any child with rickets also has osteomalacia, but the reverse is not necessarily true. [1, 2, 3, 4] Children with radiographically confirmed rickets have an increased risk of fracture. [5]
The incidence of nutritional rickets (NR) is rising globally, and hospitalization is increasing even in high-income countries. The underlying calcium deprivation manifests not only as reduced bone mineralization (rickets and osteomalacia) but also as hypocalcaemic seizures, tetany, and dilated cardiomyopathy, including cardiac failure and death. At postmortem, the prevalence of osteomalacia histologically in adult Europeans has been found to be as high as 25%. [6]
The diagnosis of nutritional rickets is made on the basis of history, physical examination, and biochemical testing and is confirmed by radiographs. [5] Plain radiography of the ametaphyseal sites (wrists and ankles) is usually performed to confirm the diagnosis. [7] The distal radius and ulna typically demonstrate rachitic lesions early on radiographs. In preterm neonates and young infants, radiographs of the knee may be more reliable than those of the wrist. In the early stage of rickets, radiographs depict no pathology; however, chemical changes in blood serum can already be found at this time. [4, 8]
(See the images of rickets below.)
Clinical findings are related to the involved skeletal site, as shown in the image below.
See 21 Hidden Clues to Diagnosing Nutritional Deficiencies, a Critical Images slideshow, to help identify clues to conditions associated with malnutrition.
Plain radiograph findings include the following:
Widening and cupping of the metaphyseal regions (see the image below)
Fraying of the metaphysis (see the images below)
Craniotabes
Bowing of long bones (see the images below)
Development of knock-knees, or genu valgum (see the image below)
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)
In more advanced stages of rickets, radiographic changes are pathognomonic; however, the underlying cause needs to be established using clinical and biochemical assessments. False-negative findings can occur in the early phase of disease.
Yasuda T. [Rickets]. Clin Calcium. 2009 Jan. 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. 2008 Mar. 46(3):195-7. [Medline].
Wagner CL, Greer FR. Prevention of rickets and vitamin D deficiency in infants, children, and adolescents. Pediatrics. 2008 Nov. 122(5):1142-52. [Medline].
Shore RM, Chesney RW. Rickets: Part II. Pediatr Radiol. 2013 Jan. 43(2):152-72. [Medline].
[Guideline] Munns CF, Shaw N, Kiely M, et al. Global Consensus Recommendations on Prevention and Management of Nutritional Rickets. J Clin Endocrinol Metab. 2016 Feb. 101 (2):394-415. [Medline]. [Full Text].
Uday S, Högler W. Nutritional Rickets and Osteomalacia in the Twenty-first Century: Revised Concepts, Public Health, and Prevention Strategies. Curr Osteoporos Rep. 2017 Aug. 15 (4):293-302. [Medline]. [Full Text].
[Guideline] Saggese G, Vierucci F, Prodam F, Cardinale F, Cetin I, Chiappini E, et al. Vitamin D in pediatric age: consensus of the Italian Pediatric Society and the Italian Society of Preventive and Social Pediatrics, jointly with the Italian Federation of Pediatricians. Ital J Pediatr. 2018 May 8. 44 (1):51. [Medline]. [Full Text].
Shiba M, Mizuno M, Kuraishi K, Suzuki H. Cervical ossification of posterior longitudinal ligament in x-linked hypophosphatemic rickets revealing homogeneously increased vertebral bone density. Asian Spine J. 2015 Feb. 9 (1):106-9. [Medline]. [Full Text].
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 Radiology, European Society of Paediatric Radiology, Nederlandse Vereniging voor Radiologie
Disclosure: Nothing to disclose.
Kieran McHugh, MB, BCh Honorary Lecturer, The Institute of Child Health; Consultant Pediatric Radiologist, Department of Radiology, Great Ormond Street Hospital for Children, London, UK
Kieran McHugh, MB, BCh is a member of the following medical societies: American Roentgen Ray Society, Royal College of Radiologists
Disclosure: Nothing to disclose.
Bernard D Coombs, MB, ChB, PhD Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.
David A Stringer, MBBS, FRCR, FRCPC Professor, National University of Singapore; Head, Diagnostic Imaging, KK Women’s and Children’s Hospital, Singapore
David A Stringer, MBBS, FRCR, FRCPC is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada, Royal College of Radiologists, Society for Pediatric Radiology, British Columbia Medical Association, European Society of Paediatric Radiology
Disclosure: Nothing to disclose.
Felix S Chew, MD, MBA, MEd Professor, Department of Radiology, Vice Chairman for Academic Innovation, Section Head of Musculoskeletal Radiology, University of Washington School of Medicine
Felix S Chew, MD, MBA, MEd is a member of the following medical societies: American Roentgen Ray Society, Association of University Radiologists, Radiological Society of North America
Disclosure: Nothing to disclose.
Beverly P Wood, MD, MSEd, PhD Professor Emerita of Radiology and Pediatrics, Division of Medical Education, Keck School of Medicine, University of Southern California; Professor of Radiology, Loma Linda University School of Medicine
Beverly P Wood, MD, MSEd, PhD is a member of the following medical societies: American Academy of Pediatrics, Association of University Radiologists, American Association for Women Radiologists, American College of Radiology, American Institute of Ultrasound in Medicine, American Medical Association, American Roentgen Ray Society, Radiological Society of North America, Society for Pediatric Radiology
Disclosure: Nothing to disclose.
Rickets Imaging
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