multiple fractures in premature very low body weight infant with rickets kwang soon song, m.d....
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![Page 1: Multiple fractures in premature very low body weight infant with rickets Kwang Soon Song, M.D. Department of Orthopedic Surgery Keimyung University Taegu,](https://reader035.vdocuments.us/reader035/viewer/2022081515/56649f065503460f94c1b8ee/html5/thumbnails/1.jpg)
Multiple fractures in premature very
low body weight infant with rickets
Kwang Soon Song, M.D.Department of Orthopedic Surgery
Keimyung University
Taegu, Korea.
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• Maternal Status : PIH(Pregnancy Induced Hypertension)
• IUP 25 W and 5 D
• C-section
• 560gm : VLBW (Very Low Body Weight)
• Bronchopulmonary dysplasia
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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)
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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)
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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
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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
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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
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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
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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
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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)
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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)
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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)
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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
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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)
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Characteristics of Fracture Characteristics of Fracture
•Metaphysis : Most•Transverse, greenstick, angulation•Callus : less than a week•No physeal disruption•Complete remodeling: 6-12months
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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
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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
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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.
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# 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