Multiple fractures in premature very low body weight infant with rickets Kwang Soon Song, M.D. Department of Orthopedic Surgery Keimyung University Taegu,

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Presentation transcript:

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

Alkaline Phosphatase (Normal : IU) Rickets : 28days ( 4 weeks)

Serum Calcium (Normal: )

Serum Phosphorus

Serum total bilirubin

Fractures ( Rt distal radius) 49 days

Fractures ( Rt proximal humerus) 50 days

Fractures ( Rt distal femur) 58 days

Fractures( Lt distal radius & ulnar) 60 days

Fractures ( Lt proximal fibular) 61 days

Fractures ( Lt distal femur) 62 days

65 days Fractures ( Rt, distal humerus, proximal ulnar, proximal femur,proximal tibia & fibula)

Fractures ( left proximal femur) 80 days

Fractures ( Rt tibia & fibula midshaft) 92 days

Fractures ( mutiple rib fracture, Lt proximal & distal humerus) 119 days

1. 1.Rt. distal radius 2. 2.Rt. proximal Humerus 3. 3.Rt. distal femur 4. 4.Lt. distal radius & ulnar 5. 5.Lt. proximal fibular 6. 6.Rt. distal humerus 7. 7.Rt. proximal femur 8. 8.Rt. proximal ulnar 9. 9.Lt. distal femur Rt. tibia & fibular mid shaft Lt. proximal femur Lt. proximal & distal humerus Multiple rib fracture

Discussion Premature : 7.5% VLBW : 1.1% Survival rate of VLBW : ( gm: 20% gm: 85-90%) Death rate of VLBW: 26.3% Incidence of Premature in USA

Incidence of fracture Premature (>2500gm & gestation: 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( gm) 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 VLBW Mean 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 time 74% : multiple Fx VLBW+Rickets : Fracture (27.1%) ( Dabezies E J et al CORR: 1997; 335, PP )

Predisposing risk factor for Rickets in VLBW 1. 1.Prolonged parenteral nutrition (hyperalimentation: >3 weeks ) 2.Hepatobiliary disease 3.Chronic diuretic therapy (>2 weeks)

Diagnosis 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 Demineralization : 4 th week Rib fracture : 6-8 th week (Robert WA et al, 1984 JPO) Long bone fracture : week Fracture : 75 days (Dabezies E et al 1997, CORR)

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

Treatment NutritionalFracture Ca & P Peripheral( IV) : 50mg/kg of Ca Central catheter :120mg/kg of Ca 55mg/kg of P Vit D: Range : IU/day VLBW: 1000 IU/day Hip spica cast with Ventilator? I mmobilization 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 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 Death