multiple fractures in premature very low body weight infant with rickets kwang soon song, m.d....
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Multiple fractures in premature very
low body weight infant with rickets
Kwang Soon Song, M.D.Department of Orthopedic Surgery
Keimyung University
Taegu, Korea.
• Maternal Status : PIH(Pregnancy Induced Hypertension)
• IUP 25 W and 5 D
• C-section
• 560gm : VLBW (Very Low Body Weight)
• Bronchopulmonary dysplasia
ALP
0
100
200
300
400
500
600
700
800
900
1000
1 16 28 40 54 61 67 74 88 98 112 130 144 156
age(days)
seru
m le
vel(
IU)
Alkaline Phosphatase (Normal : 40-122 IU)
Rickets : 28days ( 4 weeks)
Serum Calcium(Normal: 8.5-11)
0
2
4
6
8
10
12
1 16 28 40 54 61 67 70 80 92 105 118 137 151 161
Age(days)
Ser
um C
alci
um
Serum Phosphorus
0
1
2
3
4
5
6
7
8
9
1 16 28 40 54 61 67 70 80 92 105 118 137 151 161
Age(days)
Ser
um P
Serum total bilirubin
0
2
4
6
8
10
12
1 4 8 21 34 49 57 63 70 80 92 105 118 137 151 161
Age(days)
Ser
um tota
l bili
rubin
Fractures ( Rt distal radius)
ALP
0
100
200
300
400
500
600
700
800
900
1000
1 16 28 40 54 61 67 74 88 98 112 130 144 156
age(days)
seru
m le
vel(
IU)
49 days
Fractures ( Rt proximal humerus)
ALP
0
100
200
300
400
500
600
700
800
900
1000
1 16 28 40 54 61 67 74 88 98 112 130 144 156
age(days)
seru
m le
vel(
IU)
50 days
Fractures ( Rt distal femur)
ALP
0
100
200
300
400
500
600
700
800
900
1000
1 16 28 40 54 61 67 74 88 98 112 130 144 156
age(days)
seru
m le
vel(
IU)
58 days
Fractures( Lt distal radius & ulnar)
ALP
0
100
200
300
400
500
600
700
800
900
1000
1 16 28 40 54 61 67 74 88 98 112 130 144 156
age(days)
seru
m le
vel(
IU)
60 days
Fractures ( Lt proximal fibular)
ALP
0
100
200
300
400
500
600
700
800
900
1000
1 16 28 40 54 61 67 74 88 98 112 130 144 156
age(days)
seru
m le
vel(
IU) 61 days
Fractures ( Lt distal femur)
ALP
0
100
200
300
400
500
600
700
800
900
1000
1 16 28 40 54 61 67 74 88 98 112 130 144 156
age(days)
seru
m le
vel(
IU) 62 days
ALP
0
100
200
300
400
500
600
700
800
900
1000
1 16 28 40 54 61 67 74 88 98 112 130 144 156
age(days)
seru
m le
vel(
IU)
65 days
Fractures ( Rt, distal humerus, proximal ulnar, proximal femur,proximal tibia & fibula)
Fractures ( left proximal femur)
ALP
0
100
200
300
400
500
600
700
800
900
1000
1 16 28 40 54 61 67 74 88 98 112 130 144 156
age(days)
seru
m le
vel(
IU)
80 days
Fractures ( Rt tibia & fibula midshaft)
ALP
0
100
200
300
400
500
600
700
800
900
1000
1 16 28 40 54 61 67 74 88 98 112 130 144 156
age(days)
seru
m le
vel(
IU)
92 days
Fractures ( mutiple rib fracture, Lt proximal & distal humerus)
ALP
0
100
200
300
400
500
600
700
800
900
1000
1 16 28 40 54 61 67 74 88 98 112 130 144 156
age(days)
seru
m le
vel(
IU) 119 days
1. Rt. distal radius2. Rt. proximal Humerus3. Rt. distal femur4. Lt. distal radius & ulnar5. Lt. proximal fibular6. Rt. distal humerus7. Rt. proximal femur8. Rt. proximal ulnar9. Lt. distal femur10. Rt. tibia & fibular mid shaft11. Lt. proximal femur12. Lt. proximal & distal humerus13. Multiple rib fracture
1
2
3
4
5
7
8
9
10
11
12136
Discussion
•Premature : 7.5%•VLBW : 1.1%
•Survival rate of VLBW : (500-600gm: 20%
1250-1500gm: 85-90%)
•Death rate of VLBW: 26.3%
Incidence of Premature in USAIncidence of Premature in USA
Incidence of fracture Incidence of fracture
Premature (>2500gm & gestation: 20-37 Wks) 1.2% (Amir J et al ,1988, JPO)
VLBW( Very Low Body Weight : >1500gm)2.1% (Amir J et al ,1988, JPO)
10.5% (Dabezies E et al 1997, CORR)
Rickets + VLBW( 1000-1500gm) 15% (Koo wwk et al 1989, Am J Dis Child)
27.1% (Dabezies E et al 1997, CORR)
Rickets + VLBW( >800gm) 73% (Koo wwk et al 1989, Am J Dis Child)
Mean age of Rickets & Fx in VLBWMean age of Rickets & Fx in VLBW
•Rickets : at 50 days (39%)28 days in this case
•Fracture : at 75 days (10.5%)49 days –119days in this case
Missed 80% of the time74% : multiple Fx
VLBW+Rickets : Fracture (27.1%)
(Dabezies E J et al CORR: 1997; 335, PP233-239)
Predisposing risk factor for Rickets in VLBWPredisposing risk factor for Rickets in VLBW
1.Prolonged parenteral nutrition(hyperalimentation: >3 weeks )
2.Hepatobiliary disease3.Chronic diuretic therapy (>2 weeks)
Diagnosis of RicketsDiagnosis of Rickets
ALP : > 400 IU(Possibility of Rickets : ALP > 350 IU)
•Radiographic fracture : found incidentally•Pathologic finding ( Craniotabes, Bowing, Rachitic rosary, Harrison groove, enlargement of wrist & ankle): rare due to rapid development
X-ray
Characteristics of Fracture Characteristics of Fracture
•Demineralization : 4th week•Rib fracture : 6-8th week (Robert WA et al, 1984 JPO)
•Long bone fracture : 11-12 week•Fracture : 75 days (Dabezies E et al 1997, CORR)
Characteristics of Fracture Characteristics of Fracture
•Metaphysis : Most•Transverse, greenstick, angulation•Callus : less than a week•No physeal disruption•Complete remodeling: 6-12months
Upper extremity : 54%Lower extremity : 18%
Rib : 22%Scapular & clavicle : 6%
(Koo wwk et al 1989, JPO)
Upper extremity: 35.7%Lower extremity: 6.1%Rib : 55.1%Clavicle : 3.1%
Characteristics of Fracture Characteristics of Fracture
Treatment Treatment
Nutritional Fracture
Ca & P• Peripheral( IV): 50mg/kg of Ca
• Central catheter:120mg/kg of Ca 55mg/kg of P
Vit D: Range : 400-1600 IU/dayVLBW: 1000 IU/day
•Hip spica cast with Ventilator? •Immobilization for 2 weeks—deplete bone mass•Tongue blade splint?
•Aluminum splint with padding?
•Gentle nursing care?
•Avoid vigorous chest PT, passive ROM exercise
What to do What to do
•Extremity and chest radiograph should be obtained at this time in ELBW infants(rickets; 50days, fracture ; 75 days)
•Early identification and care for occult fractures in infants with rickets.
# RDS IV c SRT #2 # P-AGA, ELBWI (25 wks-560 g) # High risk infant(C-sec, m's PIH, transverse lie, m's old age) # BPD # NEC # ROP(II, zoneII, ou) # GMH(II), WMN, ventriculomegaly(mild), subependymal cyst,
tiny cystic PVL # Moderate pericardial effusion # P. aeruginosa sepsis # S. epidermidis sepsis # S. aureus sepsis # Malssesia furfur sepsis # Rickets of prematurity # Fracture of Rt. humerus & Rt. distal femur & Lt. femur # Neonatal cholestasis, hepatic dysfunction
RDS : Respiratory distress syndrome SRT : surfactant ELBWI : extremely very low birth weight infant BPD : broncopulmonary dysplasia ROP : retinopathy of premature GMH : Germinal matrix hemorrhage WNM : White matter necrosis PVL : periventricular leukomalisi
Causes of DeathCauses of Death