A 15-month-old child exclusively breastfed beyond 6 months without complementary feeds presents with bowing of both legs, a rachitic rosary, and widening of the wrist metaphyses. Calcium is low, phosphate is low, ALP is markedly elevated, and PTH is elevated. 25-OH vitamin D is 7 ng/mL. Which radiological finding is MOST characteristic of nutritional rickets?
- A Dense metaphyseal bands (Trümmerfeld zone)
- B Fraying, cupping, and splaying of the metaphysis on wrist X-ray ✓
- C Periosteal haemorrhage on long bone X-ray
- D Transverse radiolucent metaphyseal bands (Looser's zones)
Correct answer: B. Fraying, cupping, and splaying of the metaphysis on wrist X-ray
Explanation
The hallmark radiological features of nutritional rickets are fraying, cupping, and splaying of the metaphyses, best seen at the wrist (distal radius and ulna). This represents failure of mineralisation of the zone of provisional calcification. Trümmerfeld zone (zone of destruction) and metaphyseal banding are features of scurvy. Periosteal haemorrhage is characteristic of scurvy. Looser's zones (pseudofractures) are seen in osteomalacia in adults, not typically in childhood rickets. The wrist X-ray is the most sensitive radiological study for early rickets.
Reference: Ghai Essential Pediatrics, 10th ed.
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