Dr Tee Yu Jin and A.Prof Frank Gaillard et al.

Rickets, less commonly known as rachitis, refers to osteomalacia in the pediatric population that occurs before fusion of the growth plate.

Rickets is seen in a number of distinct populations which include 4:

  1. premature infants (especially if on parenteral nutrition)
  2. unbalanced infant nutrition
    • protracted exclusive breastfeeding
    • non-vitamin D supplemented formula fed infants
    • vegetarian diets
  3. maternal vitamin D deficiency
  4. lack of sun exposure
    • dark skin in sun-poor countries
    • lack of outdoor time
    • clothing that eliminates sun exposure

The onset and presentation of rickets depend on the etiology and degree of deficiency. Typically, in severe cases, rickets becomes apparent in the second year of life.

The presentation is usually with skeletal changes (see below) and bone pain.

Results from abnormality or deficiency in one or more of 1:

As a consequence of this imbalance, the ratio of mineralised to non-mineralised osteoid is abnormal (with an excess of the non-mineralised osteoid), and bone strength is reduced.

In the growing skeleton, the deficiency of normal mineralisation is most evident at metaphyseal zones of provisional calcification where there is an excess of non-mineralised osteoid resulting in growth plate widening with metaphysis flares out and appears frayed.

It is not surprising that these features are most prominent at the growth plates where growth is greatest:

  • knee: distal femur, proximal tibia
  • wrist: especially the ulna 1
  • anterior rib ends: rachitic rosary

It is important to remember that even bones that appear mineralised are weak and result in bowing, most commonly seen in the lower limbs once the child is walking. The legs bow outwards with variable deformity of the hips (both coxa vara and coxa valga are seen 1). The lower ribs may also be drawn inwards inferiorly by the attachment of the diaphragm (Harrison's sulcus).

A mnemonic to help remember these features is RICKETS.

Treatment requires correction of the metabolic imbalance. Only rarely is orthopedic surgical intervention necessary to correct skeletal deformities.

The differential for leg bowing in children includes 2:

The differential for widening of the growth plate includes:

The differential for flaring of the metaphysis includes:

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Article information

rID: 8220
Synonyms or Alternate Spellings:
  • Rhachitis
  • Rachitis

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Cases and figures

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