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This article refers to:

Nutritional rickets and vitamin D deficiency: consequences and strategies for treatment and prevention

Article title: Nutritional rickets and vitamin D deficiency: consequences and strategies for treatment and prevention

Authors: Nipith, C., David. A., & Michael, F. H.

Journal: Expert Review of Endocrinology & Metabolism

Bibliometrics: Volume 17, Number 04, pages 351-364

DOI: http://dx.doi.org/10.1080/17446651.2022.2099374

For this article, the figure 2 and its legend are replaced with the below new figure along with legend due to copyright issue.

Figure 2. Radiographic signs of rickets. Figure 2a, 2b, 2c: Growth plate changes of healing rickets mimic trauma. Patterns of healing rickets have been long recognized as mimics of fractures. These were discovered incidentally during routine x-ray surveillance of children with rickets. Figure 2a: Rachitic bucket-handle. Proximal tibia of an 8 month-old shows mineralization of the new zone of provisional calcification (ZPC) results in a bucket-handle like lesion above the original ZPC (arrows). Figure 2b: Vertical rachitic spur. Proximal fibula in an 11 month-old shows vertical projection (arrow) from the medial margin of the growth plate representing elongation of a prominent perichondrial ring (rachitic spur), mimicking a corner fracture. Figure 2c: Horizontal rachitic spur. Distal radius of a 9 month-old infant shows a horizontal projection from the medial growth plate (arrows) also representing mineralization of a thickened perichondrial ring and mimicking a corner fracture (arrow). On the follow-up study (right) the spur becomes more incorporated into the shaft as the subperiosteal osteoid mineralization progresses. Figure 2d: Posterior rib fracture in a 34 month-old child with rickets has a transverse orientation with Looser zone-like characteristics. Figure 2e: 3 month-old boy suffered a proximal femur fracture while playing with older sibling. Note bucket-handle-like features of healing rickets in the distal femur (arrow). Figure 2f: Infant with a fracture of the ulnar mid shaft has Looser-zone like properties. Note that the healing changes of the distal radius (arrow) mimic a buck-handle fracture. Figure 2g, 2h, 2i: Healing rachitic metaphyses. The recalcification appears to spread from the end of the shaft toward the epiphyseal plate instead of from the epiphyseal plate toward the end of the shaft. Figure 2g, before treatment; Figure 2h, 13^th day of healing; Figure 2i, 34^th day of healing. The apparent reversal of the direction of healing is actually due to cupping of the epiphyseal plate in this case. Deposition of calcium in the provisional zone of calcification on the floor of the cup near the end of the shaft is responsible for the factitious appearance of “diaphyseal” healing. Figure 2j: Bulbous expansion of the costochondral junction (arrow) indicates rachitic rosary. Figure 2k: “Corner fracture” in 19 month-old rachitic child. The perichondrial ring of the lower tibia had overgrown considerably during active rickets and incompletely remineralize during healing (arrow). The characteristic appearance is that of a triangular shaped bone at the periphery of the growth plate. The lucent gap separating the metaphysis from the perichondrium may be resilient to complete mineralization and require more time to become incorporated. The lack of periosteal new bone and clinical symptoms distinguished a true fracture from a fracture mimic.

Sources: Study of Developing, florid and healing rickets as demonstrated by X-ray photography. Hans Wimberger. In: Studies of rickets in Vienna 1919-22. (Report to the Accessory food factors committee appointed jointly by the Medical Research Council and the Lister Institute). Part III. No. 1. London, H. M. Stationery (Figure 2a, 2b, 2c); Vitamin D deficiency rickets and allegations of non-accidental injury. Paterson CR. Acta Paediatr. 2009 Dec;98(12):2008-12 (Figure 2d); Zitelli and Davis’ Atlas of Pediatric Physical Diagnosis, Seventh Edition (2018) 171-235. (Figure 2e); Fig 36, Rickets, Including Osteomalacia and Tetany. Alfred Hess, M.D.,Lea and Febiger, Philadelphia, 1929. (Figure 2f); Carty H. Caffey’s Pediatric X-Ray Diagnosis: An Integrated Imaging Approach. Arch Dis Child. 1993 Oct;69(4):475. (Figure 2g, 2h, 2i); Rickets as an unexpected x-ray finding. Lumpkins L, Oestreich AE.J Natl Med Assoc. 1983 Mar;75(3):255-8. (Figure 2j); Bouillon R, Marcocci C, Carmeliet G, Bikle D, White JH, Dawson-Hughes B, Lips P, Munns CF, Lazaretti-Castro M, Giustina A, Bilezikian J. Skeletal and Extraskeletal Actions of Vitamin D: Current Evidence and Outstanding Questions. Endocr Rev. 2019 Aug 1;40(4):1109-1151. (Figure 2k).