An 11 month old girl with bilateral wrist swelling

An 11 month old girl presented to the paediatric department with a lower respiratory tract infection. She also had failure to thrive and mild motor developmental delay. On examination, she had swollen wrists bilaterally. A radiograph of her right arm is shown below (fig 1)⇓. Her blood results were urea 4.3 mmol/l, creatinine 29 μmol/l, corrected calcium 2.47 mmol/l, alkaline phosphatase 3340 U/l, and phosphate 1.88 mmol/l. Fig 1 Wrist radiograph of an 11 month old girl with bilateral wrist swelling Fig 2 Wrist radiograph showing splaying, cupping, and widespread demineralisation Fig 3 Chest radiograph showing prominent costochondral joints (rachitic rosary)