Purpose or Case Report: Background: Vitamin C deficiency remains an underrecognized cause of musculoskeletal symptoms in children with suboptimal nutrition. Vitamin C plays major roles in collagen, nitric oxide, and norepinephrine formation, and is essential from the diet because humans cannot synthesize it. In children with scurvy, musculoskeletal symptoms such as limp or refusal to bear weight, occur in approximately 80% of patients. Early recognition can prevent invasive, costly workups and limit morbidity.

Objective: To characterize skeletal imaging features of scurvy in a pediatric case series.
Methods & Materials:
Methods: A retrospective five-year review of the hospital information system was performed to identify children diagnosed with scurvy. Collaboration among pediatrics, nutrition, orthopedics, and radiology departments was undertaken to elucidate presenting symptoms and imaging findings. All available musculoskeletal imaging was independently reviewed by two radiologists.
Results: Results: Six children (4 male) ranging between 3 and 16 years (median 10.5 years) had a diagnosis of scurvy with presenting musculoskeletal symptoms, including lower extremity pain, limp or difficulty ambulating. All had a developmental disability or avoidant restrictive food intake disorder with very limited or absent vitamin C sources.
Imaging: Lower extremity radiographs were performed on 5/6 children. One patient had osteopenia with a dense epiphyseal ring (Wimberger rim) in the distal femur. None showed the historically described sclerotic or lucent metaphyseal band (white line of Frankel and Trummerfeld zone respectively) or metaphyseal (Pelkan) spur.
Lower extremity MRI was performed in 4 children. Symmetric metaphyseal bone marrow edema and soft tissue edema were the most common abnormalities (n=3) followed by periosteal reaction and subperiosteal fluid (n=1). Diagnosis of nutritional deficiency was suggested in the radiology interpretation in only1 MRI (a child with metaphyseal edema and subperiosteal fluid). Differential diagnoses proposed at time of interpretation were chronic multifocal osteomyelitis, leukemia, and Langerhans cell histiocytosis.
Conclusions: Conclusion: Historically classic radiographic findings of scurvy were not present in our cohort, which may have contributed to delayed diagnosis. Scurvy should be considered when MR imaging, performed for nonspecific lower extremity symptoms, reveals symmetric metaphyseal bone marrow edema, especially in the setting of developmental disability and/or limited diet.