Methodological approach for the histological comparison between rickets and child abuse

Metaphyseal changes in rickets and child abuse-related fractures may be difficult to distinguish; therefore, it is important to follow a standardized procedure in order to detect mineralization defects of the skeleton and differentiate them from healing fractures. We present a typical post-mortem case of rickets in a 3.5-year-old boy where different diagnostic tools were applied to confirm this condition. At autopsy a rachitic rosary was seen. Vitamin D insufficiency found in laboratory analyses, metaphyseal fraying in radiography and an accumulation of non-mineralized bone (osteoid) in undecalcified histological preparations led to the correct diagnosis. This case shows that the appropriate methodology to use undecalcified bone preparations is of paramount importance to detect mineralization defects. Moreover, as in this case which involved a combination of rickets and child abuse, the situation is often more complex where neglect and abuse may lead to vitamin D insufficiency.