Bilateral Femoral Fracture in an Adolescent Male Due to Severe Vitamin D Deficiency.

PURPOSE/BACKGROUND: Mild to moderate vitamin D deficiency is common in pediatric patients in the U.S. Severe hypovitaminosis D has been linked to specific risk factors, such as female gender, obesity, winter season, darker skin, lack of exposure to the sun, and low vitamin D intake. It has been reported that adolescents usually experience less severe clinical symptoms than young children with vitamin D deficiency. We present a previously healthy 15-year-old Caucasian male with bilateral spontaneous femoral fracture due to severe hypovitaminosis rickets. He had unusual eating habits such as avoiding dairy, vegetables, and fruits. In addition to always preferring to eat alone due to anxiety. Patient is underweight with a BMI z score of -4.05 at time of presentation. Due to lack of interest in physical activities, the patient spent most of his time indoors. DESIGN/METHODS: This is a case report of a patient who presented to the children's hospital for further workup for bilateral spontaneous femoral fractures. FINDINGS/RESULTS: Laboratory work up revealed that his 25 hydoxy-vitamin D level was less than 4 ng/ml, calcium level was 5.7 mg/dl (8.4-10.5mg/dL), and phosphorus was 3.5 mg/dl (3.7-4.7 mg/dl). His intact parathyroid hormone was elevated at 555 pg/ml (14-95 pg/ml) and alkaline phosphatase was elevated at 777 U/L (91-339 U/L). A wrist x-ray showed widening of the distal radial and ulnar metaphyses with metaphyseal cupping. Further labs showed macrocytic anemia and severe vitamin B12 deficiency. Workup for malabsorption was negative. Patient underwent bilateral open hip reduction internal fixation. Hypovitaminosis D and hypocalcemia were treated with calcium carbonate and oral vitamin D3 supplements. His follow up laboratory evaluation showed normalization of his calcium, phosphorus, PTH, alkaline phosphatase, and vitamin D levels. Repeat wrist X-ray two months later revealed marked improvement in the appearance of the distal radial and ulnar growth plates and metaphyseal regions. CONCLUSIONS: This patient's vitamin D deficiency/rickets was found to be secondary to malnutrition due to limited intake, along with limited sunlight exposure. We recommend that a detailed dietary history is obtained in every adolescent patient to evaluate for proper vitamin D intake, especially in patients who are significantly underweight. If vitamin D deficiency is expected, vitamin D level should be checked and appropriate treatment should be initiated once vitamin D insufficiency is confirmed.

Femoral shaft fracture following oil massage in neonates: a single-centre experience.

Femoral shaft fractures following oil massage in newborns are very rare. We describe our observations at a tertiary centre in northern India. Three such cases encountered during the study period from July 2014 to June 2019 were evaluated. Sociocultural details, neonatal illnesses, mode of delivery, history of child abuse, type of fracture and management were recorded and analysed. All patients had a mid-shaft fracture after forceful oil massage by caring grandmothers. They all had complete union of fractures by the end of four weeks. This case series shows that mid-shaft fracture femur in neonates has excellent long-term prognosis, but the practice of oil massage needs to be modulated.

Two cases of fractures in neonates associated with maternofetal vitamin D deficiency.

Vitamin D supplementation is essential for the entire population, especially during pregnancy and in the pediatric period. We report two case studies of full-term newborns who presented long-bone fractures associated with severe vitamin D deficiency transmitted to them by their mothers, even though maternal supplementation had been implemented according to the existing recommendations. These observations encourage the investigation of neonatal vitamin D deficiency in the presence of long-bone fractures in the absence of traumatic birth and the necessity of reenforcing the means of prevention and the selection of risk groups in order to adjust vitamin D supplementation during pregnancy individually.

[Newborn and infant fractures secondary to traditional massage]. / Fractures du nouveau-né et du nourrisson secondaires au massage traditionnel.

The traditional massage of the newborn and young infant is an ancient practice in Africa and other regions. It has many benefits that are currently recognized, even in Western societies. However, it can be dangerous. We report two cases of fractures of the femur and clavicle that occurred in a 17-day-old newborn and a 1-month-old infant secondary to a traditional massage. In both cases, there was no concept of trauma or a history of osteogenesis imperfecta in the family or the presence of other fractures suggesting abuse. We concluded in a fracture caused by traditional massage in both cases. Given its many benefits as described in the literature, the traditional massage of young infants cannot be considered a harmful practice. However, it should be practiced with care to prevent the occurrence of such complications.

Improper Use of a Plant-Based Vitamin C-Deficient Beverage Causes Scurvy in an Infant.

Scurvy is a rare disease in developed countries. Risk groups include children with restricted diets, mainly patients who are autistic or have cerebral palsy. Furthermore, consumption of plant-based beverages has increased in recent years, especially in developed countries. When plant-based beverages are the exclusive diet in the first year of life and not consumed as a supplement to formula or breastfeeding, it can result in severe nutritional problems. We report a case of scurvy after exclusive intake of almond beverages and almond flour from 2.5 to 11.0 months of life. The patient was referred for pathologic fractures of the femur, irritability, and failure to thrive. He had typical radiologic signs of scurvy, such as osteopenia, cortical thinning, Wimberger ring, Frankel line, fracture, and periosteal reaction. Moreover, his plasmatic vitamin C level was very low. The child was diagnosed with scurvy and was started on vitamin C replacement therapy at a dose of 300 mg per day. Over the following 3 months, his general condition, the pain in the legs, and the radiologic features improved; the plasmatic vitamin C level was normalized; and the child started walking. In summary, this case demonstrates that scurvy is a new and severe complication of improper use of almond drinks in the first year of life. Manufacturers should indicate that these beverages are inappropriate for infants who consume a vitamin C-deficient diet.

Fixator-augmented flexible intramedullary nailing for osteopenic femoral shaft fractures in children.

Children with underlying metabolic bone diseases, such as osteogenesis imperfecta and spastic cerebral palsy, pose a challenge in the treatment of femoral shaft fractures. We performed flexible intramedullary nailing with supplemental monolateral external fixation in a subgroup of such patients. The external fixator assists in controlling angulation and rotation at the fracture site, and avoids the need for supplemental casting with its associated problems such as skin breakdown and difficulty with personal hygiene. We describe the surgical technique, pitfalls, and outcomes in a series of four patients with underlying osteopenia treated with external fixator-augmented flexible nailing for femoral shaft fractures.

A low-energy femoral shaft fracture from performing a yoga posture.

The femoral shaft is rarely the site of a low-energy fracture in a healthy individual. The vast majority of these fractures are due to major trauma such as motor vehicle accidents. Although low-energy femoral shaft fractures do occur, they are typically in patients with osteoporotic bone, or prosthesis related. In this case report, we present a man in his late 30s who was practising a specific yoga stance when he experienced a femoral shaft fracture.

Mesenchymal phosphaturic tumour: early detection of recurrence.

The case of a recurrent phosphaturic mesenchymal tumour of the maxillary sinus 10 years after the first surgical excision is reported. The neoplasm first presented with paraneoplastic osteomalacia causing a pathological femur fracture. A right maxillary sinus tumour was identified and treated thereafter. The patient had no local symptoms and serum electrolytes returned to normal after surgical removal of the tumour. However, 10 years later, the patient's urine Ca and P levels increased and an octreoscan detected a new tumour in the right maxillary sinus. Early diagnosis prevented the effects of the paraneoplastic activity of the neoplasm. This case emphasises the importance of specific, close follow-up, because the neoplasm rarely produces local signs indicating its position. To our knowledge, this is the first reported case of a late relapse presenting without relevant symptoms (local pain or swelling or pathological fractures).

Atypical femoral fractures: a review of the literature.

Bisphosphonates are the most commonly used drugs worldwide for treating osteoporosis. Atypical femoral fractures most commonly are associated with prolonged bisphosphonate use. They also may occur with denosumab use or in patients without a history of using these drugs. In this article, we provide a comprehensive review of the mechanism of action of bisphosphonate and the definition, incidence, epidemiology, pathogenesis, diagnosis, management, and prevention of atypical femoral fractures.

Pathologic femur fracture due to a brown tumor in a patient with secondary hyperparathyroidism and vitamin D-resistant rickets.

Vitamin D-resistant rickets is the common clinical outcome of multiple genetic mutations that alter the regulation of phosphorus and vitamin D metabolism, mainly through their effects on fibroblast growth factor 23 (FGF-23). These diseases typically present in childhood with the classic physical examination finding of nutritional rickets, such as genu varum/valgum and rachitic rosary. Treatment, which is aimed at improving severe bone disease with vitamin D and phosphorus supplementation, can cause secondary hyperparathyroidism and/or kidney failure from nephrocalcinosis over the life of the patient. Although FGF-23 has been shown to downregulate parathyroid hormone in vitro, its effect on parathyroid secretion in disease states such as chronic kidney disease and X-linked hypophosphatemic rickets is unclear because elevations in FGF-23 and parathyroid hormone levels characterize both of these disease states. We describe a case of vitamin D-resistant rickets that presented with a femur fracture through a brown tumor. Radiographs show the combination of severe bony abnormalities associated with both long-standing hyperparathyroidism and vitamin D-resistant rickets.

Exogenous phytoestrogenic molecule icaritin incorporated into a porous scaffold for enhancing bone defect repair.

This study was designed to develop a bioactive scaffold to enhance bone defect repair in steroid-associated osteonecrosis (SAON). Icaritin, a metabolite of the herb Epimedium, has been identified as an angiogenic and osteogenic phytomolecule. Icaritin was homogenized into poly lactic-co-glycolic acid/tricalcium phosphate (PLGA/TCP) to form an icaritin-releasing porous composite scaffold (PLGA/TCP/icaritin) by fine-spinning technology. In vitro, high performance liquid chromatography was used to determine the release of icaritin during degradation of PLGA/TCP/icaritin. The osteogenic effects of PLGA/TCP/icaritin were evaluated using rat bone marrow mesenchymal stem cells (BMSCs). In vivo, the osteogenic effect of PLGA/TCP/icaritin was determined within a bone tunnel after core decompression in SAON rabbits and angiography within scaffolds was examined in rabbit muscle pouch model. In vitro study confirmed the sustainable release of icaritin from PLGA/TCP/icaritin with the bioactive scaffold promoting the proliferation and osteoblastic differentiation of rat BMSCs. In vivo study showed that PLGA/TCP/icaritin significantly promoted new bone formation within the bone defect after core decompression in SAON rabbits and enhanced neovascularization in the rabbit muscle pouch experiment. In conclusion, PLGA/TCP/icaritin is an innovative local delivery system that demonstrates sustainable release of osteogenic phytomolecule icaritin enhancing bone repair in an SAON rabbit model. The supplement of scaffold materials with bioactive phytomolecule(s) might improve treatment efficiency in challenging orthopedic conditions.

Antiresorptive drugs (bisphosphonates), atypical fractures and rebound effect: new evidence of similitude.

BACKGROUND: Homeopathy is based on treatment by similitude ('like cures like') administering to sick individuals substances that cause similar symptoms in healthy individuals, employing the secondary and paradoxical action of the organism as therapeutic response. This vital or homeostatic reaction of the organism can be scientifically explained by the rebound effect of drugs, resulting in worsening of symptoms after suspension of treatment. Bisphosphonates (BPs) reduce 'typical' fractures in patients with osteoporosis, but recent studies report 'atypical' fractures of the femur after stopping the BPs, a rebound effect may be the causal mechanism. METHOD: Review of the literature concerning the relationship between atypical femoral fractures and antiresorptive drugs (bisphosphonates), identifying the pathogenesis of this adverse event. RESULTS: Several studies have described multiple cases of 'atypical' low-impact subtrochanteric stress fractures or complete fractures of the femur. These fractures are often bilateral, preceded by pain in the affected thigh, may have a typical X-ray appearance, and may delayed healing. Rebound of osteoclastic activity after suspension of antiresorptive drugs is a plausible mechanism to explain this phenomenon. CONCLUSION: As for other classes of drugs, the rebound effect of antiresorptive drugs supports Hahnemann's similitude principle (primary action of the drugs followed by secondary and opposite action of the organism), and clarifies this 'unresolved' issue. Unfortunately, the rebound effect is little discussed among health professionals, depriving them of important knowledge ensure safe management of drugs.

[Calcium deficiency: a problem in growing and adult dogs: two case reports]. / Kalziummangel - bei wachsenden und ausgewachsenen Hunden ein Problem. Zwei Fallberichte.

Two case reports demonstrate the consequences of a deficient calcium supply in dogs. The first case describes an adult dog with a history of food allergy. The dog had been fed with an unbalanced elimination diet (no minerals and vitamins supplemented) over many years and was referred with the diagnosis of osteomalacia (rubber jaw) for optimization of his ration. The second case refers to a puppy which was fed a homemade diet without supplementing the missing minerals and vitamins and suffered a femur fracture after moderate physical impact. In both cases, the computer-aided ration calculation showed a suboptimal to severely deficient supply for several minerals and vitamins, in particular calcium whereas serum calcium levels were normal. Both dogs recovered after being fed a complete and balanced diet. In conclusion, a survey of the feeding using ration calculation is essential especially in the case of potential nutrition-related skeletal disorders. Serum calcium levels cannot be used as a tool to diagnose nutritional calcium deficiency.

A biomechanical comparison of periprosthetic femoral fracture fixation in normal and osteoporotic cadaveric bone.

Several techniques are described for fixation of Vancouver B1 femoral shaft fractures after total hip arthroplasty. Twenty-four femurs were scanned by dual x-ray absorptiometry scanned and matched for bone mineral density. Femurs were implanted with a cemented simulated total hip prosthesis with a simulated periprosthetic femur fracture distal to the stem. Fractures were fixed with Synthes (Paoli, Pa) 12-hole curved plates and 4 different constructs proximally. Each construct was loaded to failure in axial compression. Constructs with locking and nonlocking screws demonstrated equivalent loads at failure and were superior in load at failure compared with cables. Cable constructs failed proximally. No proximal failures occurred in specimens fixed with screws and cables. A combination of locked or nonlocked screws and supplemental cable fixation is recommended for the treatment of Vancouver B1 periprosthetic femur fractures.

Spontaneous supracondylar femoral fracture in an HIV patient in lotus position.

Bone disorders have been described in patients chronically infected with human immunodeficiency virus (HIV). A case of spontaneous supracondylar femoral fracture that occurred in a 58-year-old monk during meditation is reported. His AIDS disease was controlled with combination antiretroviral therapy. Vitamin D and calcium had been added 3yr before since osteoporosis was detected by dual-energy X-ray absorptiometry (DXA). At the time of the fracture, the patient was on treatment with 35mg every week of sodium risedronate, 1000mg of calcium, and 400IU of Vitamin D every day. Clinical use of DXA for HIV patients should be considered as a routine measure to help reducing risk for fractures.

Intra-articular lateral femoral condyle fracture following an ACL revision reconstruction.

Lateral femoral condyle fractures following an ACL reconstruction are rare. To our knowledge, this is the first case report of a lateral femoral condyle fracture following a revision ACL reconstruction. The patient's fracture was intra-articular, had a significant amount of soft tissue damage, and was further complicated by a large defect involving the bone tunnel from the ACL revision reconstruction. The patient was treated with an open reduction and internal fixation and recovered well.

[Polyspecialistic treatment of a polytrauma. Case report]. / Politrauma complesso: gestione poli-specialistica. Caso clinico.

The Authors report the clinical course of M.L., a 22 years old man. He came to our observation after a road accident, in third care. In the former hospital admissions hemodynamic stabilization, surgical haemostasis of multiple hepatic lacerations with hemoperitoneum and right leg amputation were performed. He arrived to our department in a critical condition owing to mild respiratory insufficiency due to many rib fractures with sero-haematic spillage into the pleural cavity, in dialytic treatment for acute renal insufficiency consequent to right renal artery damage, soft tissues necrosis of the amputation stump with sepsis and persistent fever until 40 degrees C. The treatment and care of this patient required a team-work with the collaboration of many specialists, namely surgeons, nephrologists, anaesthetists, interventionist radiologists and hyperbaric oxygen therapy experts. Thanks to such collaboration we achieved an excellent quoad vitam result. The aim of this paper is to confirm and emphasize the central role of a Trauma Team, fed in a Trauma Center and in a Trauma System, in the management of complex traumas.

Hyperhomocysteinemia is associated with impaired fracture healing in mice.

Hyperhomocysteinemia (HHCY) has been shown to disturb bone metabolism and to increase the incidence of osteoporosis and osteoporotic fractures. However, there is a complete lack of information on whether these metabolic alterations affect bone repair. The aim of this study was to analyze the impact of HHCY on fracture healing. One group of mice was fed a homocystine-supplemented diet (n = 12), whereas another group received the accordant standard diet for control (n = 13). Four weeks after the stable fixation of a closed femoral fracture, animals were killed to prepare bones for histomorphometric and biomechanical analyses. In addition, blood samples were obtained to evaluate serum concentration of homocysteine (HCY). Quantitative analysis of blood samples revealed severe HHCY as indicated by significantly increased serum concentrations of HCY in animals fed the homocystine-supplemented diet (102.2 +/- 64.5 micromol/l) compared to controls (2.8 +/- 1.5 micromol/l). Biomechanical evaluation of bone repair revealed significantly decreased bending stiffness of the femora of homocystine-fed animals (45.5 +/- 18.2 N/mm) compared with controls (64.6 +/- 15.8 N/mm). Histomorphometric analysis demonstrated a slightly smaller callus diameter in HHCY animals but no significant differences in the tissue composition of the callus. In conclusion, the homocystine-supplemented diet leads to severe HHCY, which is associated with an impaired biomechanical quality of the healing bone.

Epidemiological investigation of femoral fractures in market pigs and the associated economic implications.

The cause of an increased number of femoral fractures in market pigs from a single producer is described. Blood chemical, bone ash, radiographic, and feed analyses revealed that the fractures were caused by insufficient calcium in the diet. Associated economic and welfare implications are discussed.

Supracondylar femur fracture after knee manipulation: a report of 3 cases.

Supracondylar femur fracture is a rare but devastating complication of knee manipulation following total knee arthroplasty (TKA). Avoidance of this complication can be achieved by careful attention to the indications and contraindications, timing, and technique of closed manipulation. We performed a retrospective chart and radiographic review to identify all patients who underwent closed manipulation under anesthesia for a diagnosis of aseptic arthrofibrosis after TKA. This article presents 3 cases of supracondylar femur fracture following closed knee manipulation of stiff TKAs that occurred at our institution over a 4-year period (1999-2002). Patient age ranged from 44 to 73 years. All patients underwent cruciate retaining TKA. Time from TKA to manipulation ranged from 3 months to 3 years. Two patients sustained an extension type supracondylar fracture. Two of the 3 patients were treated with closed reduction and casting/bracing. At a minimum 8-month follow-up after fracture, range of motion was poor with average flexion to 77 degrees and average flexion contracture of 13 degrees . In our patients, risk factors for fracture included prolonged time from arthroplasty to manipulation, arthrofibrosis, radiographic osteopenia, and rheumatoid arthritis. To our knowledge, this represents the largest case series of iatrogenic supracondylar femur fractures reported in the literature. Two manipulation techniques are described in detail. The alternative manipulation technique is highlighted with no fractures or complications over the same period. We believe that the alternative manipulation technique is a safe and effective technique to manipulate stiff TKA's and has been used for over >10 years by the senior surgeon (J.V.B.).