Rickets is described as a disease of infancy and childhood in which there is inadequate mineralization of growing bone.



Rickets is the clinical consequence of impaired mineralization of bone matrix through the growing skeleton in children.



Bone is mineralized by the crystallization of calcium and phosphates in the presence of alkaline phosphatase enzyme.



Rickets is a failure of or delays in calcification of newly formed bone at long-bone physis.

Calcipenic rickets: Calcium deficiency or interruption in the supply, metabolism, or utilization of vitamin D.


Dietary Calcium deficiency


Nutritional vitamin D deficiency


Vitamin D deficiency secondary to malabsorption, liver disease, renal insufficiency


25-hydroxylase deficiency


Vitamin D dependent rickets type I


Vitamin D dependent rickets type II



Phosphopenic rickets: Inadequate dietary phosphate intake or excess renal tubular loss.


Primary – X-linked hypophosphatemic rickets, autosomal dominant hypophosphatemic rickets, autosomal recessive hypophosphatemic rickets, X-linked recessive and hereditary hypophosphatemia with hypercalciuria


Secondary – Oncogenic osteomalacia (Tumour induced osteomalacia), Fibrous dysplasia [McCune Albright syndrome], Epidermal nevus syndrome, ifosfamide nephrotoxicity, Fanconi syndrome, low dietary phosphate intake



Alkaline phosphatase deficiency



The clinical manifestations of rickets include changes in growth-plate morphology, with decreased longitudinal growth and angular deformities of the long bones.



The skeletal abnormalities of severe rickets present in early childhood and often before the age of 2 years.



The child may have a history consistent with hypocalcemia in infancy, including apneic spells, convulsions, tetany, and stridor prior to the age of months.



The child is often hypotonic with delayed motor activity milestones for sitting, crawling, and walking.



There is proximal muscle weakness and sometimes profuse sweating.



Cardiomyopathy, respiratory and gastrointestinal infections may accompany the clinical presentation.



Signs of rickets in osseous tissue


Craniotabes in the newborn and young infant


Rickets hydrocephalus – Frontal bossing in early infancy due to expansion of cranial bones relative to facial bones


Caput quadratum or Hot cross bun appearance – Delayed closure of fontanelle and sutures are thickened


Delayed primary dentition – Deciduous incisors not present by 9 months and first molar by 14 months


Enamel hypoplasia and greater susceptibility to caries in the first dentition


Rachitic rosary – Beading enlargement at the costochondral junction (Specificity 64%)


Harrison’s sulcus – Indentation of lower ribs caused by indrawing on the softened ribs


Pigeon chest – Chest cage narrowed transversely and elongated anteroposteriorly


Pot-belly – Protuberent abdomen with separation of recti muscle


Pelvis – Compressed transversely by weight bearing, narrow inlet


Spine – Kyphoscoliosis


Widened wrists – An apparent bracelet of bone around the wrist (Specificity 81%)


The string of pearls deformity – Sausages like enlargement of ends of phalanges and metacarpals


Enlarged epiphysis – Elbow, knee, and ankle



Skeletal deformities –


Genu varum


Coxa vara


Anterolateral bowing of the femur


Lateral bowing with the rotation of tibia – rachitic saber shin


Genu valgum (Older children)

The earliest sign is osteopenia



Followed by a widening of the growth plate from the proliferation of uncalcified cartilage and osteoid



Followed by metaphyseal widening, splaying, cupping, and fraying



There are four stages of rickets –


Stage I – Normal rounded appearance of the epiphysis is replaced by a cloudy area containing one or more indistinct centers of ossification. The metaphysis is splayed out and deficient in calcium shadow.


Stage II – Epiphysis is mottled, irregular, and ill-defined. The metaphysis is ragged, broader than normal running out from the side.


Stage III – Shadow becomes denser and at the end of metaphysis a dense line appears. There is a marked difference in size between the end of shaft and epiphysis.


Stage IV – Increase in the breadth of metaphysis is still present. Bone is clearly defined and shows a normal content of calcium.