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Figure 1. A 30-month-old girl had had progressive bowing of the legs since she began walking at the age of 11 months. She reported bilateral thigh pain. Physical examination revealed genu varum (Panel A) and enlarged wrists. A radiograph of the wrists revealed cupping and fraying of the metaphyses of the distal radius and ulna (Panel B). The child's serum alkaline phosphatase and parathyroid hormone concentrations were high, the serum calcium concentration was low, and the serum 25-hydroxyvitamin D concentration was normal (35 ng per milliliter [87 nmol per liter]). She was usually exposed to sunlight for more than three hours a day. She had stopped breast-feeding at the age of six months, and her average dietary calcium intake was 160 mg per day.
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