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Acute leukemia of childhood may present with various clinical manifestations that mimic orthopaedic conditions. The osseous radiographic abnormalities of this disease, although well described in the literature, are not pathognomonic, and certain changes may not be as frequent as was previously thought. In a retrospective study, we reviewed the cases of 107 patients, less than eighteen years old, who had been seen at the Winnipeg Children's Hospital. The mean follow-up was 4.6 years for the fifty-eight patients who were still alive and 2.0 years for the forty-nine non-survivors. In twenty-two (20.6 per cent) of the patients, the presenting complaints were pain in the extremities, back pain, osteomyelitis, septic arthritis, or fracture. The radiographic abnormalities, which were present in forty-seven (43.9 per cent) of the children at the time of diagnosis, were osteopenia, lytic lesions, metaphyseal bands, periosteal new bone, and sclerotic lesions. Since the initial symptoms of leukemia commonly involve the musculoskeletal system, a high index of suspicion must be maintained by orthopaedic surgeons.