Physical Examination
Generalized muscular hypotonia of an unknown mechanism is observed in most patients with clinical (as opposed to biochemical and radiographic) signs of rickets. Craniotabes (areas of thinning and softening of bones of the skull) manifests early in infants with vitamin D deficiency, although this feature may not be present in infants, especially those born prematurely.
If rickets occurs at a later age, thickening of the skull develops. This produces frontal bossing and delays the closure of the anterior fontanelle. In the long bones, laying down of uncalcified osteoid at the metaphases leads to spreading of those areas, producing knobby deformity, which is visualized on radiography as cupping and flaring of the metaphyses.
Weight bearing produces deformities such as bowlegs and knock-knees.
In the chest, knobby deformities results in the so-called rachitic rosary along the costochondral junctions. The weakened ribs pulled by muscles also produce flaring over the diaphragm, which is known as Harrison groove. The sternum may be pulled into a pigeon-breast deformity.
In more severe instances in children older than 2 years, vertebral softening leads to kyphoscoliosis. The ends of the long bones demonstrate that same knobby thickening. At the ankle, palpation of the tibial malleolus gives the impression of a double epiphysis (Marfan sign). Because the softened long bones may bend, they may fracture on one side of the cortex (ie, greenstick fracture). [6]
Manifestations of rickets are illustrated in the image below.
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Findings in patients with rickets.
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Anteroposterior and lateral radiographs of the wrist of an 8-year-old boy with rickets demonstrates cupping and fraying of the metaphyseal region.
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Radiographs of the knee of a 3.6-year-old girl with hypophosphatemia depict severe fraying of the metaphysis.
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Radiograph in a 4-year-old girl with rickets depicts bowing of the legs caused by loading.
