Widened physes with frayed, cupped, splayed metaphyses at the wrist and knee, plus a rachitic rosary and bowing; healing shows as a dense zone of provisional calcification returning.
Orient first
- Nutritional vitamin D deficiency is the commonest cause worldwide; renal and hypophosphataemic forms exist.
- Changes are most visible where growth is fastest: distal radius and ulna, distal femur, proximal tibia, anterior rib ends.
- Metaphyseal fractures in rickets are not the classic metaphyseal lesion of abuse, but both must be considered.
Acquire the study
- PA radiograph of one wrist and AP of one knee; follow-up at 3 months to confirm healing.
The manoeuvre
- Wrist PA: physeal widening in mm, metaphyseal fraying, cupping and splaying of the distal radius and ulna.
- Knee AP: same metaphyseal changes at the distal femur and proximal tibia; bowing of the tibia.
- Bone density: generalised osteopenia, thin cortices, coarse trabeculae.
- Chest radiograph (if taken): widened anterior rib ends (rosary).
- Follow-up: return of the zone of provisional calcification — a dense metaphyseal line.
What confirms it
- Metaphyseal fraying and cupping with physeal widening, with biochemistry (vitamin D, calcium, phosphate, ALP).
What licenses you to exclude it
- A sharp zone of provisional calcification at the wrist and knee excludes active rickets.
The classic misread
- Calling normal metaphyseal cupping at the ulna in a toddler rickets — look for fraying and physeal widening.
- Forgetting to look for fractures and Looser zones.