Definition
A disorder of defective collagen synthesis from vitamin C deficiency, causing bleeding, bone pain and impaired endochondral bone formation.
Aetiology
- Vitamin C is a cofactor for prolyl and lysyl hydroxylase in collagen cross linking
- Restricted diets in children with autism, developmental delay or avoidant restrictive food intake disorder
- Older age, alcohol dependence, malabsorption and dialysis in adults
Clinical Features
- Limp, leg pain, refusal to walk and pseudoparalysis in children
- Gum swelling and bleeding, perifollicular haemorrhage and corkscrew hairs
- Subperiosteal haemorrhage, haemarthrosis and muscle haematoma
- Costochondral beading, the scorbutic rosary
- Fatigue, anaemia and poor wound healing
Investigations
- Serum ascorbic acid below 2.5 mg/L confirms the diagnosis
- Wimberger ring, a sclerotic rim around an osteopenic epiphysis
- Frankel line, a dense metaphyseal zone of provisional calcification
- Trümmerfeld zone, a lucent band beneath the Frankel line
- Pelkan spurs at the metaphyseal margins
- Ground glass osteopenia with pencil thin cortices
- Subperiosteal haemorrhage calcifies and becomes visible with treatment
- MRI shows multifocal marrow oedema that can mimic leukaemia or CRMO
Differential Diagnosis
- Rickets
- Leukaemia
- Acute osteomyelitis
- Non-accidental injury
- Chronic recurrent multifocal osteomyelitis
- Juvenile chronic arthritis
Management
- Vitamin C replacement. Oral ascorbic acid, with pain relief within days
- Dietary review. Dietitian and feeding team input to prevent recurrence
- Limb protection. Epiphyseal separation can occur before healing
Prognosis
- Rapid symptomatic response, with radiographic healing over months
References
- Fain O. Musculoskeletal manifestations of scurvy. Joint Bone Spine. 2005, 72(2), 124-8. PubMed
- Alten ED, Chaturvedi A, Cullimore M, Fallon AA, Habben L, Hughes I, O’Malley NT, Rahimi H, Renodin-Mead D, Schmidt BL, Weinberg GA, Weber DR. No longer a historical ailment. Two cases of childhood scurvy with recommendations for bone health providers. Osteoporos Int. 2020, 31(5), 1001-5. PubMed
Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 19 October 2026.