Common presenting symptoms of acute lymphoblastic leukemia in children are well known and include pallor, fatigue, and loss of appetite. Limb pain is sometimes described and can be misleading. We describe two recent cases seen in our emergency department, where vertebral fractures, a much rarer finding, were the only presenting symptoms that led to the diagnosis. One case had been thoroughly evaluated only 5 weeks prior to the diagnosis and included magnetic resonance imaging. The second patient was rapidly referred to our center with a history of acute lumbar pain. Emergency physicians caring for children must be aware of this rare type of presentation of leukemia.