A 12-year-old girl presented with inability to gain height and difficulty getting up from the floor. She did not have pain in her joints or muscles. Her height was 142 cm and weight 38 kg. Neurological examination was normal, including bulk and strength of muscles of lower limbs. However, broadening of the wrists and “double malleoli” sign were observed. Blood investigations showed 25-hydroxy vitamin D 4.5 ng/mL (normal: 30-50), calcium 8 mg/dL (normal: 8.5-10.5), phosphorus 4.5 mg/dL (normal: 2.5-4.5), and alkaline phosphatase 440 U/L (normal: 45-150). Creatine phosphokinase, erythrocyte sedimentation rate, and C-reactive protein were normal. Radiograph of the wrists showed irregularity of the distal metaphyses of radius and ulna, giving rise to a frayed appearance (Figure 1A). The finding is suggestive of severe rickets. The girl was treated with cholecalciferol and calcium. A repeat radiograph of the hands 6 months later showed marked improvement (Figure 1B).
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