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

2. Maternal Status : PIH (Pregnancy Induced Hypertension) IUP 25 W and 5 D C-section 560gm : VLBW (Very Low Body Weight) Bronchopulmonary dysplasia

3. Alkaline Phosphatase (Normal : 40-122 IU) Rickets : 28days ( 4 weeks)

4. Serum Calcium (Normal: 8.5-11)

5. Serum Phosphorus

6. Serum total bilirubin

7. Fractures ( Rt distal radius) 49 days

8. Fractures ( Rt proximal humerus) 50 days

9. Fractures ( Rt distal femur) 58 days

10. Fractures( Lt distal radius & ulnar) 60 days

11. Fractures ( Lt proximal fibular) 61 days

12. Fractures ( Lt distal femur) 62 days

13. 65 days Fractures ( Rt, distal humerus, proximal ulnar, proximal femur,proximal tibia & fibula)

14. Fractures ( left proximal femur) 80 days

15. Fractures ( Rt tibia & fibula midshaft) 92 days

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

17. 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 10. 10.Rt. tibia & fibular mid shaft 11. 11.Lt. proximal femur 12. 12.Lt. proximal & distal humerus 13. 13.Multiple rib fracture 1 2 3 4 5 7 8 9 10 11 12 136

18. 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 USA

19. 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)

20. 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, PP233-239)

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

22. 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

23. Characteristics of Fracture Demineralization : 4 th week Rib fracture : 6-8 th week (Robert WA et al, 1984 JPO) Long bone fracture : 11-12 week Fracture : 75 days (Dabezies E et al 1997, CORR)

24. Characteristics of Fracture Metaphysis : Most Transverse, greenstick, angulation Callus : less than a week No physeal disruption Complete remodeling: 6-12months

25. 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

26. Treatment NutritionalFracture Ca & P Peripheral( IV) : 50mg/kg of Ca Central catheter :120mg/kg of Ca 55mg/kg of P Vit D: Range : 400-1600 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

27. 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.

28. # 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