Acute lymphoblastic leukemia (ALL) is one of the most common hematological malignancies occurring in children. We report an interesting case of ALL with an unusual presentation. This 3-year-old boy came with a 6 month history of multiple pathological fractures, generalized osteopenia and vertebral compression. All the possible causes responsible for this condition were ruled out. His complete blood count which was normal initially evolved into cytopenias. His physical examination revealed generalized lymphadenopathy and hepatosplenomegaly. The complete blood count showed pancytopenia with blasts in peripheral smear. Bone marrow aspirate was suggestive of B ALL. Pediatric ALL patients usually present with symptoms due to cytopenias, fever and bone pains. Although asymptomatic skeletal involvement may be seen in 40-60% of patients at presentation, pathological fractures and vertebral compressions are very rare. Therefore a high index of suspicion is needed to diagnose such cases. Moreover, these patients are usually associated with good prognostic features.