This document discusses multiple potential causes of fractures in infants that can be mistakenly attributed to child abuse, including metabolic bone diseases, prematurity, and nutritional deficiencies. It notes that fractures from metabolic causes often involve no pain, no soft tissue damage, and no dislocations, unlike traumatic fractures. It emphasizes the need for differential diagnosis to rule out conditions like rickets, scurvy, osteopenia of prematurity, and immobilization-related bone loss before accusing parents of abuse. Failure to consider other causes can lead to misdiagnosis of abuse when fractures actually have metabolic origins.
Vinchon M Sdh In Infants Can It Occur Spontaneously Childs Nerv Sys 2010[1]alisonegypt
This study examines cases of subdural hematoma (SDH) in infants that were considered to have occurred spontaneously rather than from nonaccidental trauma. The study identified 16 cases of spontaneous SDH in infants (SSDHI) from a prospective database that met criteria for lack of trauma history or suspicious findings. Most SSDHI cases involved males and had predisposing factors like macrocephaly, arachnoidomegaly, or obstetric complications. The study aims to better characterize SSDHI and identify risk factors to differentiate it from cases of traumatic SDH caused by nonaccidental injury.
This systematic review analyzed 32 studies comparing skeletal fracture patterns in abused and non-abused children. The review found that fractures resulting from abuse occurred throughout the skeletal system, most commonly in infants and toddlers. Multiple fractures and rib fractures had the highest probability of being caused by abuse. Certain fracture types, locations, and the developmental stage of the child can help determine the likelihood of abuse. However, more high-quality comparative research is still needed.
Demographics, mechanism of injury, injury severity, and associated injury pro...TÀI LIỆU NGÀNH MAY
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tai lieu tong hop, thu vien luan van, luan van tong hop, do an chuyen nganh
This document summarizes key findings from the ASBMR 2015 conference related to diabetes and bone health. It describes several studies presented at the conference that investigated the relationship between type 1 and type 2 diabetes and fracture risk. One study found that elderly men with type 2 diabetes did not have an increased risk of vertebral fractures compared to non-diabetic men. Another study found that measures of bone microarchitecture and glycemic control, rather than bone mineral density, were predictors of fractures in individuals with type 1 diabetes. A third study found evidence of altered trabecular microarchitecture in the tibia of youth with type 1 diabetes compared to controls.
1) The document discusses the management of pregnant patients requiring surgery or experiencing trauma. It notes special considerations for pregnant patients, including physiological changes and the need to care for both mother and fetus.
2) In trauma situations, the initial focus is stabilizing the mother to benefit both patients. Penetrating injuries often directly threaten the fetus while blunt trauma poses less direct risk, usually resulting in placental abruption or preterm labor.
3) Surgical decisions must weigh fetal viability against maternal stability, with non-urgent cases delayed if possible. Monitoring includes fetal heart monitoring and ultrasound to detect issues like abruption.
The Perception of Transtibial Amputees Regarding the Use of Prosthesesinventionjournals
International Journal of Humanities and Social Science Invention (IJHSSI) is an international journal intended for professionals and researchers in all fields of Humanities and Social Science. IJHSSI publishes research articles and reviews within the whole field Humanities and Social Science, new teaching methods, assessment, validation and the impact of new technologies and it will continue to provide information on the latest trends and developments in this ever-expanding subject. The publications of papers are selected through double peer reviewed to ensure originality, relevance, and readability. The articles published in our journal can be accessed online.
Austin Pediatrics is an open access, peer reviewed, scholarly journal committed to publish articles in all areas of science and practice of Pediatrics.
The aspire of the journal is to present a platform for scientists and academicians all over the world to encourage, distribute, and discuss various new issues and developments in different areas of Pediatrics and to promote responsible and balanced debate on controversial issues that influence child health, including non-clinical areas such as ethics, law, surroundings and economics.
Austin Pediatrics accepts innovative research articles, review articles, case reports and rapid communication on all the aspects of Pediatrics.
Austin Pediatrics is an open access, peer reviewed, scholarly journal committed to publish articles in all areas of science and practice of Pediatrics.
This document discusses organ donation shortages in the US and emerging technologies like 3D bioprinting of organs and head transplants as potential solutions. It notes that over 120,000 people are on organ transplant waitlists in the US despite only 2.5 million annual deaths. 3D bioprinting of tissues and organs could help by producing customized organs without rejection risks. The document also discusses a planned first human head transplant by Dr. Sergio Canavero to treat a 30-year-old man's rare genetic disorder that cannot be addressed by gene editing alone. The head transplant would be an attempt to treat the man's condition which currently has a life expectancy of around 20 years.
Vinchon M Sdh In Infants Can It Occur Spontaneously Childs Nerv Sys 2010[1]alisonegypt
This study examines cases of subdural hematoma (SDH) in infants that were considered to have occurred spontaneously rather than from nonaccidental trauma. The study identified 16 cases of spontaneous SDH in infants (SSDHI) from a prospective database that met criteria for lack of trauma history or suspicious findings. Most SSDHI cases involved males and had predisposing factors like macrocephaly, arachnoidomegaly, or obstetric complications. The study aims to better characterize SSDHI and identify risk factors to differentiate it from cases of traumatic SDH caused by nonaccidental injury.
This systematic review analyzed 32 studies comparing skeletal fracture patterns in abused and non-abused children. The review found that fractures resulting from abuse occurred throughout the skeletal system, most commonly in infants and toddlers. Multiple fractures and rib fractures had the highest probability of being caused by abuse. Certain fracture types, locations, and the developmental stage of the child can help determine the likelihood of abuse. However, more high-quality comparative research is still needed.
Demographics, mechanism of injury, injury severity, and associated injury pro...TÀI LIỆU NGÀNH MAY
Để xem full tài liệu Xin vui long liên hệ page để được hỗ trợ
: https://www.facebook.com/thuvienluanvan01
HOẶC
https://www.facebook.com/garmentspace/
https://www.facebook.com/thuvienluanvan01
https://www.facebook.com/thuvienluanvan01
tai lieu tong hop, thu vien luan van, luan van tong hop, do an chuyen nganh
This document summarizes key findings from the ASBMR 2015 conference related to diabetes and bone health. It describes several studies presented at the conference that investigated the relationship between type 1 and type 2 diabetes and fracture risk. One study found that elderly men with type 2 diabetes did not have an increased risk of vertebral fractures compared to non-diabetic men. Another study found that measures of bone microarchitecture and glycemic control, rather than bone mineral density, were predictors of fractures in individuals with type 1 diabetes. A third study found evidence of altered trabecular microarchitecture in the tibia of youth with type 1 diabetes compared to controls.
1) The document discusses the management of pregnant patients requiring surgery or experiencing trauma. It notes special considerations for pregnant patients, including physiological changes and the need to care for both mother and fetus.
2) In trauma situations, the initial focus is stabilizing the mother to benefit both patients. Penetrating injuries often directly threaten the fetus while blunt trauma poses less direct risk, usually resulting in placental abruption or preterm labor.
3) Surgical decisions must weigh fetal viability against maternal stability, with non-urgent cases delayed if possible. Monitoring includes fetal heart monitoring and ultrasound to detect issues like abruption.
The Perception of Transtibial Amputees Regarding the Use of Prosthesesinventionjournals
International Journal of Humanities and Social Science Invention (IJHSSI) is an international journal intended for professionals and researchers in all fields of Humanities and Social Science. IJHSSI publishes research articles and reviews within the whole field Humanities and Social Science, new teaching methods, assessment, validation and the impact of new technologies and it will continue to provide information on the latest trends and developments in this ever-expanding subject. The publications of papers are selected through double peer reviewed to ensure originality, relevance, and readability. The articles published in our journal can be accessed online.
Austin Pediatrics is an open access, peer reviewed, scholarly journal committed to publish articles in all areas of science and practice of Pediatrics.
The aspire of the journal is to present a platform for scientists and academicians all over the world to encourage, distribute, and discuss various new issues and developments in different areas of Pediatrics and to promote responsible and balanced debate on controversial issues that influence child health, including non-clinical areas such as ethics, law, surroundings and economics.
Austin Pediatrics accepts innovative research articles, review articles, case reports and rapid communication on all the aspects of Pediatrics.
Austin Pediatrics is an open access, peer reviewed, scholarly journal committed to publish articles in all areas of science and practice of Pediatrics.
This document discusses organ donation shortages in the US and emerging technologies like 3D bioprinting of organs and head transplants as potential solutions. It notes that over 120,000 people are on organ transplant waitlists in the US despite only 2.5 million annual deaths. 3D bioprinting of tissues and organs could help by producing customized organs without rejection risks. The document also discusses a planned first human head transplant by Dr. Sergio Canavero to treat a 30-year-old man's rare genetic disorder that cannot be addressed by gene editing alone. The head transplant would be an attempt to treat the man's condition which currently has a life expectancy of around 20 years.
1) THA can provide better outcomes than fixation for displaced femoral neck fractures, but presents unique challenges including risk of intraoperative fracture and leg length discrepancy.
2) Care must be taken to choose a press-fit femoral stem and supplement acetabular fixation to reduce risk of intraoperative fracture. The C-arm is important for guiding component placement and assessing leg length.
3) Recovery from THA after fracture may be more difficult than for osteoarthritis due to associated soft tissue injury, so managing expectations is important.
This document summarizes the history of osteoporosis in Ireland over the past 3 millennia. It discusses key developments like the first use of DXA scanning in 1990, establishment of the Irish Osteoporosis Society in 1996, and current issues like the need for better prevention, earlier diagnosis, and a multidisciplinary approach. It highlights important contributors to the field and their research. Overall, it provides a high-level overview of osteoporosis treatment and management in Ireland from ancient times to the present.
Megaprosthetic replacement of knee in a young boy of 14 yearsApollo Hospitals
Now a days, Total Knee Replacement (TKR) is a common for elderly patients but is an uncommon procedure in young individuals. Recently, limb conservation surgery for malignant bone tumours like osteosarcoma around the knee has become a common indication for TKR in young. We report, here a histologically confirmed osteosarcoma in right
proximal tibia of a 14-year-old boy who was managed successfully by limb salvage surgery using Global Modular Replacement System (GMRS, Stryker).
This document summarizes information about cancer logistics and genetics. It discusses how normal cells can develop mutations during cell division, leading to cancer. Genetic mapping of genes has helped determine cancer risks and treatments. The document also covers DNA and genetic testing, how mutations occur, cancer inheritance patterns, and statistics on cancer survival rates. Prevention methods like avoiding smoking and limiting alcohol are discussed as ways to reduce cancer risks.
This newsletter provides updates from the UTMB Department of Orthopaedic Surgery and Rehabilitation (DOSR). The Chair discusses the DOSR's mission to be among the best orthopaedic departments through commitment from all members. The DOSR has enhanced clinical productivity, education, and research. New clinical trials and faculty recognition are mentioned. Honors, publications, and presentations by DOSR members are listed. The newsletter provides information on Grand Rounds speakers and incoming residents. Expansion of the voluntary faculty is noted.
This document discusses the relationship between cognition and frailty in older adults. It notes that frailty is characterized by loss of physiological reserve and increased vulnerability, while cognitive impairment is a strong predictor of adverse health outcomes. Several studies have found associations between physical frailty and cognitive function, with higher frailty levels linked to increased risk of mild cognitive impairment and dementia. The mechanisms underlying the relationship between frailty and cognition are unclear but may involve shared pathways like vascular disease, inflammation, and metabolic changes. The concept of "cognitive frailty" is proposed for those with both physical frailty and mild cognitive impairment to recognize their combined effects on health outcomes.
This curriculum vitae summarizes the qualifications and experience of Dr. Nikolaos T. Chalvatzis, an ophthalmologist currently working as an Assistant Professor in Ophthalmology in Thessaloniki, Greece. It outlines his educational background, including medical degrees from Aristotle University, a PhD in ocular surface diseases, and postdoctoral training in the UK. It also details his current clinical and teaching responsibilities, areas of specialty, extensive surgical experience, academic awards, publications, society memberships, and research interests focused on ocular surface disorders and orbital pathology.
This document provides biographical and professional information about Marcel Martin, including:
- His education, including a master's thesis in 2004 at Université de Sherbrooke.
- His extensive research experience as a full professor of surgery from 1998-2013 at various universities and hospitals.
- His publications, awards, grants, skills, and scientific memberships.
- Links to his profile on ResearchGate and a list of publications.
The document discusses the lack of funding for childhood cancer research and the effects this has on adult survivors. It notes that while survival rates are around 80%, survivors suffer from late effects of toxic treatments well into adulthood. These late effects include increased risk of secondary cancers, heart problems, infertility and bone issues. Survivors also face psychological burdens like low self-esteem and fear of recurrence. However, more funding is needed to find better treatments that reduce late effects and allow survivors to live full lives. Currently, only 15% of funding goes to research on improving survivor outcomes and quality of life. More awareness is needed to increase funding and help both current and future childhood cancer patients and survivors.
Cervical acceleration/deceleration injuries, also known as whiplash associated disorders, involve injury to the neck from sudden back-and-forth motion and can cause neck pain, dizziness, or neuropraxia. Symptoms are usually self-limiting but may require conservative treatments like medication, physical therapy, or vestibular rehabilitation. Rarely, cervical spine injuries from whiplash can be life-threatening if they damage blood vessels or the spinal cord. Those at highest risk include participants in contact sports or motor racing.
The document discusses mortality risk after fractures. It summarizes several studies that find the risk of mortality is significantly increased after osteoporotic fractures, especially hip fractures. The mortality increase is seen primarily in the first few months or years after fracture. The causes of excess post-fracture mortality include infections, cardiac disease, and other comorbidities. Several factors influence mortality risk, including pre-fracture health status, the presence of other fractures or dysmobility conditions, and use of bisphosphonate treatment after fracture.
Fibula Nail for Unstable Ankle FracturesArun Shanbhag
Ankle fractures are becoming more common, especially in elderly females. While open reduction and internal fixation is often used in younger patients, complications are higher in elderly patients. The fibula nail provides a minimally invasive technique for unstable ankle fractures in elderly patients. It involves inserting a nail into the distal fibula through a small incision. This affords stable fixation with less soft tissue disruption and prominent hardware, leading to lower complication rates compared to open plating. The fibula nail is well-suited for unstable ankle fractures in elderly patients who are at higher risk for complications from traditional open procedures.
This newsletter provides information on recent literature in breast cancer and other oncology fields, upcoming conferences, and a discussion forum for specialists. It includes summaries of 10 recent papers on topics like triple negative breast cancer treatment and outcomes of tamoxifen therapy. The editor announces a new online community for specialists called Senology.org - International Senologic and Oncologic Scientific Community within Doctorsbook.com.
This letter discusses an alternative perspective on the cause of metaphyseal fractures in three newborn infants described in another study. While the original study attributed the fractures to twisting and pulling during difficult deliveries, the author argues that fetal immobilization is a more likely explanation. Decreased fetal movement from conditions like breech presentation, maternal diabetes, or tight fetal confinement can reduce bone mineralization and strength at birth. This "transient brittle bone state" may predispose newborns to fractures during delivery, rather than the fractures necessarily indicating child abuse as sometimes assumed. The author disagrees with views that dismiss other causes and considers metaphyseal fractures to always indicate abuse without prior accidental injury history.
Dr. Marvin Miller Unexplained Fractruesalisonegypt
This letter discusses an alternative perspective on the cause of metaphyseal fractures in three newborn infants described in another study. While the original study attributed the fractures to twisting and pulling during difficult deliveries, the author argues that fetal immobilization is a more likely explanation. Decreased fetal movement from conditions like breech presentation, maternal diabetes, or tight fetal confinement can reduce bone mineralization and strength at birth. This "transient brittle bone state" may predispose newborns to fractures during delivery, rather than the fractures necessarily indicating child abuse as sometimes assumed. The author disagrees with views that dismiss other causes and considers metaphyseal fractures to always indicate abuse without prior accidental injury history.
This letter discusses an alternative perspective on the cause of metaphyseal fractures in three newborn infants described in another study. While the original study attributed the fractures to twisting and pulling during difficult deliveries, the author argues that fetal immobilization is a more likely explanation. Decreased fetal movement from conditions like breech presentation, maternal diabetes, or tight fetal confinement can reduce bone mineralization and strength at birth. This "transient brittle bone state" may predispose newborns to fractures during delivery, rather than the fractures necessarily indicating child abuse as sometimes assumed. The author disagrees with views that dismiss other causes and considers metaphyseal fractures to always indicate abuse without prior accidental injury history.
The document discusses physeal (growth plate) injuries in children. It notes that physeal injuries represent 15-20% of injuries in children and can cause growth arrest and deformities. The most common sites are the distal radius, distal tibia, and phalanges. It describes the anatomy and blood supply of the physis. It discusses the Salter-Harris classification system for physeal fractures and treatment approaches including casting, splinting, and surgery. Complications of physeal injuries like growth arrest, angular deformity, and limb length discrepancy are also summarized. Long term follow up is needed to monitor bone healing and growth.
This document discusses pediatric bone densitometry and factors that can impact bone development and density in children. It covers normal skeletal development processes and factors like nutrition, physical activity, musculoskeletal disorders, and hormonal status that can negatively influence bone mineral density and increase the risk of osteoporosis if not properly addressed during childhood and adolescent years when bone mass is being established. Imaging options like DXA scans are important for assessing bone density in pediatric patients at risk of inadequate bone growth.
Osteochondritis dissecans (OCD) is a condition where pieces of bone or cartilage break off near a joint. It most commonly affects the knees, elbows, and ankles of young, active individuals. The cause is likely multi-factorial, involving vascular, genetic, biomechanical, and endochondral ossification factors that create a vulnerable area in the bone or cartilage. Diagnosis involves examining the patient's history and symptoms and may include imaging tests like x-rays or MRI. Treatment depends on the maturity of the bones and stability of the lesion.
The document discusses fractures in children and how they differ from adult fractures. It notes that children's bones are still growing, more springy, and have looser periosteum. Fractures in children can be categorized as birth fractures, epiphyseal injuries, fractures of long bone shafts, or pathological fractures. Epiphyseal injuries are further classified using the Salter-Harris system. Most children's fractures can be treated conservatively through methods like casting, traction, or slings. Complications can include growth disturbances, brachial artery injuries, or avascular necrosis.
1) THA can provide better outcomes than fixation for displaced femoral neck fractures, but presents unique challenges including risk of intraoperative fracture and leg length discrepancy.
2) Care must be taken to choose a press-fit femoral stem and supplement acetabular fixation to reduce risk of intraoperative fracture. The C-arm is important for guiding component placement and assessing leg length.
3) Recovery from THA after fracture may be more difficult than for osteoarthritis due to associated soft tissue injury, so managing expectations is important.
This document summarizes the history of osteoporosis in Ireland over the past 3 millennia. It discusses key developments like the first use of DXA scanning in 1990, establishment of the Irish Osteoporosis Society in 1996, and current issues like the need for better prevention, earlier diagnosis, and a multidisciplinary approach. It highlights important contributors to the field and their research. Overall, it provides a high-level overview of osteoporosis treatment and management in Ireland from ancient times to the present.
Megaprosthetic replacement of knee in a young boy of 14 yearsApollo Hospitals
Now a days, Total Knee Replacement (TKR) is a common for elderly patients but is an uncommon procedure in young individuals. Recently, limb conservation surgery for malignant bone tumours like osteosarcoma around the knee has become a common indication for TKR in young. We report, here a histologically confirmed osteosarcoma in right
proximal tibia of a 14-year-old boy who was managed successfully by limb salvage surgery using Global Modular Replacement System (GMRS, Stryker).
This document summarizes information about cancer logistics and genetics. It discusses how normal cells can develop mutations during cell division, leading to cancer. Genetic mapping of genes has helped determine cancer risks and treatments. The document also covers DNA and genetic testing, how mutations occur, cancer inheritance patterns, and statistics on cancer survival rates. Prevention methods like avoiding smoking and limiting alcohol are discussed as ways to reduce cancer risks.
This newsletter provides updates from the UTMB Department of Orthopaedic Surgery and Rehabilitation (DOSR). The Chair discusses the DOSR's mission to be among the best orthopaedic departments through commitment from all members. The DOSR has enhanced clinical productivity, education, and research. New clinical trials and faculty recognition are mentioned. Honors, publications, and presentations by DOSR members are listed. The newsletter provides information on Grand Rounds speakers and incoming residents. Expansion of the voluntary faculty is noted.
This document discusses the relationship between cognition and frailty in older adults. It notes that frailty is characterized by loss of physiological reserve and increased vulnerability, while cognitive impairment is a strong predictor of adverse health outcomes. Several studies have found associations between physical frailty and cognitive function, with higher frailty levels linked to increased risk of mild cognitive impairment and dementia. The mechanisms underlying the relationship between frailty and cognition are unclear but may involve shared pathways like vascular disease, inflammation, and metabolic changes. The concept of "cognitive frailty" is proposed for those with both physical frailty and mild cognitive impairment to recognize their combined effects on health outcomes.
This curriculum vitae summarizes the qualifications and experience of Dr. Nikolaos T. Chalvatzis, an ophthalmologist currently working as an Assistant Professor in Ophthalmology in Thessaloniki, Greece. It outlines his educational background, including medical degrees from Aristotle University, a PhD in ocular surface diseases, and postdoctoral training in the UK. It also details his current clinical and teaching responsibilities, areas of specialty, extensive surgical experience, academic awards, publications, society memberships, and research interests focused on ocular surface disorders and orbital pathology.
This document provides biographical and professional information about Marcel Martin, including:
- His education, including a master's thesis in 2004 at Université de Sherbrooke.
- His extensive research experience as a full professor of surgery from 1998-2013 at various universities and hospitals.
- His publications, awards, grants, skills, and scientific memberships.
- Links to his profile on ResearchGate and a list of publications.
The document discusses the lack of funding for childhood cancer research and the effects this has on adult survivors. It notes that while survival rates are around 80%, survivors suffer from late effects of toxic treatments well into adulthood. These late effects include increased risk of secondary cancers, heart problems, infertility and bone issues. Survivors also face psychological burdens like low self-esteem and fear of recurrence. However, more funding is needed to find better treatments that reduce late effects and allow survivors to live full lives. Currently, only 15% of funding goes to research on improving survivor outcomes and quality of life. More awareness is needed to increase funding and help both current and future childhood cancer patients and survivors.
Cervical acceleration/deceleration injuries, also known as whiplash associated disorders, involve injury to the neck from sudden back-and-forth motion and can cause neck pain, dizziness, or neuropraxia. Symptoms are usually self-limiting but may require conservative treatments like medication, physical therapy, or vestibular rehabilitation. Rarely, cervical spine injuries from whiplash can be life-threatening if they damage blood vessels or the spinal cord. Those at highest risk include participants in contact sports or motor racing.
The document discusses mortality risk after fractures. It summarizes several studies that find the risk of mortality is significantly increased after osteoporotic fractures, especially hip fractures. The mortality increase is seen primarily in the first few months or years after fracture. The causes of excess post-fracture mortality include infections, cardiac disease, and other comorbidities. Several factors influence mortality risk, including pre-fracture health status, the presence of other fractures or dysmobility conditions, and use of bisphosphonate treatment after fracture.
Fibula Nail for Unstable Ankle FracturesArun Shanbhag
Ankle fractures are becoming more common, especially in elderly females. While open reduction and internal fixation is often used in younger patients, complications are higher in elderly patients. The fibula nail provides a minimally invasive technique for unstable ankle fractures in elderly patients. It involves inserting a nail into the distal fibula through a small incision. This affords stable fixation with less soft tissue disruption and prominent hardware, leading to lower complication rates compared to open plating. The fibula nail is well-suited for unstable ankle fractures in elderly patients who are at higher risk for complications from traditional open procedures.
This newsletter provides information on recent literature in breast cancer and other oncology fields, upcoming conferences, and a discussion forum for specialists. It includes summaries of 10 recent papers on topics like triple negative breast cancer treatment and outcomes of tamoxifen therapy. The editor announces a new online community for specialists called Senology.org - International Senologic and Oncologic Scientific Community within Doctorsbook.com.
This letter discusses an alternative perspective on the cause of metaphyseal fractures in three newborn infants described in another study. While the original study attributed the fractures to twisting and pulling during difficult deliveries, the author argues that fetal immobilization is a more likely explanation. Decreased fetal movement from conditions like breech presentation, maternal diabetes, or tight fetal confinement can reduce bone mineralization and strength at birth. This "transient brittle bone state" may predispose newborns to fractures during delivery, rather than the fractures necessarily indicating child abuse as sometimes assumed. The author disagrees with views that dismiss other causes and considers metaphyseal fractures to always indicate abuse without prior accidental injury history.
Dr. Marvin Miller Unexplained Fractruesalisonegypt
This letter discusses an alternative perspective on the cause of metaphyseal fractures in three newborn infants described in another study. While the original study attributed the fractures to twisting and pulling during difficult deliveries, the author argues that fetal immobilization is a more likely explanation. Decreased fetal movement from conditions like breech presentation, maternal diabetes, or tight fetal confinement can reduce bone mineralization and strength at birth. This "transient brittle bone state" may predispose newborns to fractures during delivery, rather than the fractures necessarily indicating child abuse as sometimes assumed. The author disagrees with views that dismiss other causes and considers metaphyseal fractures to always indicate abuse without prior accidental injury history.
This letter discusses an alternative perspective on the cause of metaphyseal fractures in three newborn infants described in another study. While the original study attributed the fractures to twisting and pulling during difficult deliveries, the author argues that fetal immobilization is a more likely explanation. Decreased fetal movement from conditions like breech presentation, maternal diabetes, or tight fetal confinement can reduce bone mineralization and strength at birth. This "transient brittle bone state" may predispose newborns to fractures during delivery, rather than the fractures necessarily indicating child abuse as sometimes assumed. The author disagrees with views that dismiss other causes and considers metaphyseal fractures to always indicate abuse without prior accidental injury history.
The document discusses physeal (growth plate) injuries in children. It notes that physeal injuries represent 15-20% of injuries in children and can cause growth arrest and deformities. The most common sites are the distal radius, distal tibia, and phalanges. It describes the anatomy and blood supply of the physis. It discusses the Salter-Harris classification system for physeal fractures and treatment approaches including casting, splinting, and surgery. Complications of physeal injuries like growth arrest, angular deformity, and limb length discrepancy are also summarized. Long term follow up is needed to monitor bone healing and growth.
This document discusses pediatric bone densitometry and factors that can impact bone development and density in children. It covers normal skeletal development processes and factors like nutrition, physical activity, musculoskeletal disorders, and hormonal status that can negatively influence bone mineral density and increase the risk of osteoporosis if not properly addressed during childhood and adolescent years when bone mass is being established. Imaging options like DXA scans are important for assessing bone density in pediatric patients at risk of inadequate bone growth.
Osteochondritis dissecans (OCD) is a condition where pieces of bone or cartilage break off near a joint. It most commonly affects the knees, elbows, and ankles of young, active individuals. The cause is likely multi-factorial, involving vascular, genetic, biomechanical, and endochondral ossification factors that create a vulnerable area in the bone or cartilage. Diagnosis involves examining the patient's history and symptoms and may include imaging tests like x-rays or MRI. Treatment depends on the maturity of the bones and stability of the lesion.
The document discusses fractures in children and how they differ from adult fractures. It notes that children's bones are still growing, more springy, and have looser periosteum. Fractures in children can be categorized as birth fractures, epiphyseal injuries, fractures of long bone shafts, or pathological fractures. Epiphyseal injuries are further classified using the Salter-Harris system. Most children's fractures can be treated conservatively through methods like casting, traction, or slings. Complications can include growth disturbances, brachial artery injuries, or avascular necrosis.
Crimson Publishers-Fragility Hip Fracture and Sarcopenia: Which One Comes Fir...CrimsonPublishersGGS
The document discusses how sarcopenia, the loss of skeletal muscle mass and strength that occurs with aging, is an important risk factor for fragility fractures in elderly patients. It explains that sarcopenia can both lead to falls, the main cause of fractures, and result from immobilization after a hip fracture. The author argues that prevention and treatment of sarcopenia should be a priority in fragility fracture prevention programs.
This document discusses the nursing care priorities for a patient named Mrs. Gibson who suffered a hip fracture. It outlines her risk factors for osteoporosis including her age, sex, and use of corticosteroids. The immediate nursing priorities are treating her urinary tract infection with IV fluids and antibiotics, managing her pain, and positioning her on a soft surface. Post-operatively, priorities include managing pain, early mobilization to prevent complications, and reducing her risk of secondary fractures through osteoporosis treatment and fall prevention. A multidisciplinary approach is recommended for optimal recovery.
Proposal to National Science Foundation co-authored by Ian Nieves and James Earthman. It describes using FEA simulation and advanced computer-assisted fabrication techniques to develop materials for bone regeneration.
Growth plate & Various disorders affecting growth plate by Dr.VinayVenkat Vinay
This document summarizes a presentation on bone development and growth plate structure and function. It discusses the two types of ossification, intramembranous and endochondral, and describes the microscopic structure and zones of the growth plate. It also covers disorders that can affect the growth plate, including developmental dysplasias, metabolic conditions, infections, hormones, and trauma. Specific dysplasias discussed in detail include hereditary multiple exostosis, achondroplasia, hypochondroplasia, and dyschondrosteosis.
This is an old article circa 2002 that is an excellant overview of selective spinal immobilization. Since I am having trouble finding it online anymore, I put it here for all to read and enjoy. I did not write it nor do I came any copywrite for it.
This document provides a review and update on congenital scoliosis. It begins by classifying vertebral anomalies causing congenital scoliosis into failures of formation, segmentation, or both. The natural history and progression of curves depends on the type and location of the anomaly. Patient evaluation focuses on physical exam, imaging to identify the anomaly, and screening for associated anomalies. Surgical treatment aims to intervene early before large curves develop and utilizes modern techniques like spinal instrumentation.
Paediatric orthopaedic fracture; dislocation -lec 9 (june 2016) n.c.yasser Amr
Paediatric bone has unique properties compared to adult bone including less density, more porosity, and thicker periosteum. These properties lead to different fracture patterns and healing processes in children. Key areas of paediatric long bones include the epiphysis, physis, and metaphysis. The periosteum also plays an important role in healing. Remodelling allows paediatric fractures to reshape over time with growth. Certain injuries to the physis can cause deformities if not addressed.
This document discusses ankle fractures in children. It provides details on:
1) The unique anatomy of the child's ankle including the physis and its development over time.
2) Common fracture patterns seen in children of different ages depending on the stage of osseous development.
3) The importance of achieving adequate reduction and protecting the physis to avoid growth alterations or deformities.
4) Guidelines for diagnosis including physical exam, imaging like x-rays and CT, and classifications systems like Salter-Harris that influence treatment and prognosis.
This document discusses the importance of fetal movement for proper skeletal development. Reduced or absent fetal movement can lead to joint contractures, thin and brittle bones, and overall growth issues in infants. This condition is known as fetal akinesia deformation sequence (FADS). Animal models and genetic studies have provided evidence that mechanical stimulation from fetal movement is crucial for coordinating cartilage and bone development through various cell signaling pathways. A better understanding of how movement impacts skeletogenesis could help develop preventative and therapeutic approaches for skeletal disorders.
Osteoporosis: Classification, Causes, Symptoms, Treatment & Prevention
In this article, we’ll discuss what osteoporosis is, osteoporosis definition, osteoporosis types, osteoporosis causes, osteoporosis symptoms, osteoporosis medicine, osteoporosis treatment and osteoporosis prevention.
Osteoporosis:
Osteoporosis is a condition of low bone mass and decay of bone tissue prompting bone delicacy and conceivably breaking with numerous preventable and intrinsic danger factors. Osteoporosis influences bones and makes them more defenseless against sudden and unanticipated breaks and breakage. The term osteoporosis is derived from the Greek words osteon (bone) and poros (pore). For complete article, click on the given link, https://diseases8804.blogspot.com/2021/08/all-you-need-to-learn-about-osteoporosis.html
Osteoarthritis is a progressive degenerative joint disease characterized by the breakdown and eventual loss of articular cartilage in the joints. As cartilage breaks down, bones rub together causing pain, swelling, and loss of motion of the joints. The most common joints affected are weight-bearing joints like the hips, knees, and spine. Risk factors include age, obesity, joint injury, genetics, and repetitive joint stress from certain occupations and sports. The breakdown of cartilage is caused by an imbalance between the normal synthesis and degradation of cartilage components by chondrocytes within the cartilage. This leads to loss of cartilage cushioning between bones and development of bone spurs and cysts at the joint margins over time.
Osteoarthritis is a progressive degenerative joint disease characterized by the breakdown of cartilage in joints. It involves the inflammation of one or more joints and the gradual loss of cartilage over time. As cartilage breaks down, the bones underneath rub together causing pain, swelling, and loss of motion in the joints. Risk factors include age, obesity, joint injury, genetics, and repetitive stress on joints. The disease process occurs as cartilage is damaged faster than it can be repaired, leading to further breakdown and loss of cartilage cushioning between bones.
These fractures occur through the growth plate in children and can affect bone growth. There are several classifications of growth plate fractures based on the structures involved - the physis, metaphysis, and epiphysis. The Salter-Harris classification system categorizes injuries based on the extent and location within these structures. The classification is important for guiding treatment and anticipating potential long-term complications on bone growth.
Similar to Multiple Fractures From Metabolic Bone Disease (20)
1) The study examined the impact of maternal vitamin D status on fetal skeletal development through 3D ultrasound measurements in 424 pregnant women.
2) It found that suboptimal maternal vitamin D status was associated with increased femur cross-sectional area and splaying in utero, resembling signs of rickets.
3) This suggests that ensuring optimal maternal vitamin D levels during pregnancy may be important for proper fetal skeletal development.
Vitamin D Deficiency In Pre Birth Studiesalisonegypt
1) Lower maternal vitamin D status was associated with greater femoral metaphyseal cross-sectional area and higher femoral splaying index in fetuses at 19 weeks and 34 weeks gestation, suggesting maternal vitamin D insufficiency can influence fetal femoral development as early as 19 weeks.
2) Over 30% of mothers had vitamin D levels considered insufficient or deficient. Lower maternal vitamin D levels were related to increased femoral splaying and larger femoral cross-sectional area in fetuses.
3) The findings suggest that improving maternal vitamin D status early in pregnancy through supplementation may help support optimal fetal bone development.
Vita D Perrine Cg Ea At Adherence To Vit D Recommendations Among Us Infants P...alisonegypt
This study examined adherence to vitamin D recommendations among US infants using data from the Infant Feeding Practices Study II from 2005-2007. The researchers estimated the percentage of infants meeting the 2003 and 2008 vitamin D recommendations from the American Academy of Pediatrics at various ages from 1 to 10.5 months. They found that use of oral vitamin D supplements was low, ranging from 1% to 13% regardless of whether infants were breastfed, formula-fed, or mixed-fed. Most infants did not consume adequate amounts of vitamin D according to the 2008 recommendation, suggesting pediatricians should encourage vitamin D supplementation for breastfed and partially breastfed infants.
Vita D Supple Breatfed Infants Pediatrics 2010alisonegypt
This document summarizes a study examining the use of supplemental vitamin D among infants who were breastfed for prolonged periods. The study found that among infants who were predominantly breastfed for at least 6 months, the rate of receiving supplemental vitamin D was only 15.9%. Parental decisions about vitamin D supplementation were significantly associated with whether the parent agreed their pediatrician recommended it and whether they believed breast milk contains all needed nutrition. Educational efforts are needed to increase compliance with guidelines recommending all breastfed infants receive vitamin D supplementation.
Vita D Defic Mothers Newborns Merewood Pediatrics 2010alisonegypt
This study found high rates of vitamin D deficiency in mothers and newborns in Boston, Massachusetts. 58% of infants and 36% of mothers had vitamin D levels below 20 ng/mL. Risk factors for infant deficiency included a deficient mother, winter birth, black race, and a maternal BMI over 35. Prenatal vitamin use was protective against deficiency for both mothers and infants, however 30% of mothers still had low vitamin D levels despite taking prenatal vitamins.
Vita D Defic Insuffic Pregnancy Johnson Am J Perinatol 2010alisonegypt
This study found that vitamin D deficiency and insufficiency are common among pregnant women in the United States, especially for African American and Hispanic women. The study measured vitamin D levels in 154 African American, 194 Hispanic, and 146 Caucasian pregnant women early in their pregnancies. It found that 97% of African American women, 81% of Hispanic women, and 67% of Caucasian women had insufficient or deficient vitamin D levels. African American women were the most likely to have deficiency, while Caucasian women were the most likely to have sufficient levels. Race was identified as the most important risk factor for deficiency or insufficiency.
This document discusses trial tactics and techniques based on the advice of experienced litigators. It recommends gaining experience through taking on as many trials as possible in one's early career, even if they are minor cases. While advocacy skills can be learned, experience trying many cases, preferably dozens per year, is the best teacher. Different advocates have different styles as well, so one should not slavishly copy others but develop their own approach. Overall, industry, hard work, and experience are more important than innate talent for most advocates to achieve success.
1) Recent reports in England have outlined issues with forensic science evidence and its presentation in courts, including concerns about biases towards prosecution experts.
2) There is a large funding gap between the prosecution and publicly funded defense, undermining the principle of a fair trial.
3) English courts have been reluctant to assess the reliability and validity of novel scientific techniques, allowing potentially unreliable evidence that has contributed to past miscarriages of justice.
The Next Innocence Project Law Reivew On Sbsalisonegypt
The article discusses shaken baby syndrome (SBS) convictions and new scientific research casting doubt on the forensic significance of the diagnostic triad used to convict hundreds of caregivers. It presents the case of Audrey Edmunds, who was convicted of murder and sentenced to 18 years in prison based solely on expert testimony that an infant suffered from SBS, despite no evidence the caregiver shook the baby. New research has undermined the triad as proof of shaking and removed shaking from the syndrome. However, the criminal justice system has been slow to incorporate this, and triad-based convictions continue regularly. The author argues this constitutes a criminal justice crisis requiring resolution.
This document summarizes the changing role of expert witnesses in court. It discusses how expert witnesses are traditionally expected to say whatever can reasonably support the client's position, rather than provide objective assistance. Courts have taken a more aggressive role in screening out "junk" testimony. One reform is the "gatekeeper" role of judges to exclude dubious expertise, based on criteria like testing and peer review. However, studies show judges rarely discuss these criteria and more often exclude evidence based on relevance or witness qualifications. There is a clash between the legal system's need for settled conclusions and experts' view that some issues have no settled answer. Through screening and cross-examination, the legal process does not always succeed at exposing problematic expert testimony that could lead
Strengthening Forensic Science A Way Station On The Way To Justicealisonegypt
1) The document discusses the need to strengthen forensic science through ongoing validation research to determine which practices are scientifically valid and the limits of their validity.
2) It proposes a series of "validation investigations" be conducted by a respected body like the National Academy of Sciences to determine if certain forensic techniques and theories have already been scientifically validated or not.
3) The validation investigations would examine all prior studies to determine if a technique has been validated, has not been validated, or has been found invalid. This would provide clarity on forensic practices and could reveal issues requiring re-examination of past convictions.
The document discusses the scientific and legal history of shaken baby syndrome. It describes the medical theory behind shaken baby syndrome - that violently shaking an infant can cause subdural hematomas and retinal hemorrhages leading to death. It notes the debate between experts who support the theory and those who are critical of it. The author argues that this is a genuine battle between qualified experts on both sides, and that expert testimony from both sides should be admitted in court under the Daubert and Kumho standards for expert testimony."
This document discusses shaken baby syndrome (SBS) cases and challenges the prevailing assumptions around SBS. It summarizes that shaking alone cannot cause the injuries typically associated with SBS, and that many other causes could result in retinal hemorrhages and subdural hematomas. It provides tips for challenging SBS claims using Daubert motions and expert witnesses in biomechanics, radiology, neurology and pathology that can argue alternative causes. Contact information is given for several medical experts who may be willing to review cases or testify that the injuries were not necessarily caused by shaking.
This case involves a negligence claim brought by L.C. and L.S. against the Ministry of Children and Families regarding their investigation into injuries sustained by L.C.'s infant son, D.C. D.C. was found to have a serious skull fracture and was initially removed from L.C.'s care. The Ministry conducted an investigation but L.C. maintained her innocence. The key issues are whether the Ministry owed a duty of care to L.C. and L.S., whether the Ministry breached the standard of care in its investigation, and whether any breach caused damages.
This document summarizes the growing issue of vitamin D deficiency (DD) in infants and children. It discusses how DD rates have risen significantly in recent decades across diverse populations. Multiple factors are contributing to the problem, including decreased food fortification of vitamin D, more sun avoidance behaviors, increased obesity rates, and longer breastfeeding durations without adequate supplementation. The document outlines how DD can manifest radiographically as softening of the skull and indistinct facial bones in young infants, as well as subtle metaphyseal changes in the long bones that could be mistaken for abuse-related fractures without consideration of the underlying DD.
The Canadian Paediatric Surveillance Program is a national surveillance system that identifies cases of rare diseases in children through the participation of over 2300 pediatricians. A recent study using this program identified over 100 cases of vitamin D deficiency rickets in Canadian children. National surveillance systems are important for collecting epidemiological data on uncommon conditions to answer research questions and guide public health policy. The Canadian Paediatric Surveillance Program provides valuable data and stimulates collaborative research that can improve children's health.
Nutritional rickets, once thought to be conquered, has reemerged as a public health issue in the United States. Recent case reports have highlighted dark-skinned breastfed infants, especially those in northern latitudes without vitamin D supplementation, as being most vulnerable. This article reviews a seminal 1917 study by Alfred Hess on using cod liver oil to prevent rickets in a black community in New York. The study found that cod liver oil effectively prevented and treated rickets in African American infants. Hess's success led to the development of the first rickets clinic and was an important step in overcoming the early 20th century rickets epidemic through vitamin D supplementation.
1. Multiple Fractures from Metabolic Bone Disease,
being Falsely Attributed to Inflicted Child Abuse:
Harold E Buttram, MD
One of the defining differences between traumatic fractures and those of metabolic
origin is a prevalence of shearing, severance, and/or major dislocations in fractures of
traumatic origin as compared with their absence or rarity on those of metabolic origin.(1)
A second defining difference is the absence of pain and discomfort in metabolic
fractures. Traumatic fractures, in contrast, are almost always extremely painful. This is
easily explained. It is well known that bone has no pain fibers, while surrounding
connective tissues are abundantly supplied with pain fibers. In metabolic fractures, which
can take place with ordinary infant handling, surrounding connective tissue is not
involved. In traumatic fractures, surrounding connective tissues are torn resulting in
significant pain, as anyone who has experienced a sprained ankle or traumatic rib
fractures can testify.
Current Standards of Medical Practice Concerning Multiple Fractures,
and the Requirement for Differential Diagnosis
As reported by Jenny C, Committee on Child Abuse and Neglect, in “Evaluating
infants and young children with multiple fractures,” Pediatrics,(2)(2006), a differential
diagnosis of child abuse should include the following list, with appropriate evaluation for
each, according to currently recognized medical standards. Anything less should be
considered as substandard medical practice.
‘ Osteogenesis imperfecta
‘ Preterm birth (osteopenia of prematurity)
‘ Rickets
‘ Osteomyelitis
‘ Copper deficiency
‘ Disuse demineralization from paralysis
‘ Other rare conditions (e.g. Menkes Syndrome)
Two additions might legitimately be added to this; First, classical scurvy from
vitamin C was characterized by multiple fractures. Vitamin C deficiency is still quite
prevalent and may be a contributory factor in many cases of brittle bone disease. This is
due to the essential role of vitamin C as an enzymatic cofactor for the conversion of the
amino acid, proline, into procollagen and collagen tissue, the latter making up 90 % of
bone mass. (3) Second, based largely on the pioneering work of Marvin Miller
(reviewed below), disuse demineralization of bone will take place in any situation
involving prolonged immobilization of bone. This is well documented in children with
club feet subjected to prolonged immobilization in corrective casts, as well as in animals
sent into the weightlessness of space in early experiments by the Soviet Union. As a
matter of common observation, it may be a complication of prolonged bed rest. Finally,
1
2. the immobilization of the fetus from any cause during the last trimester of
pregnancy may result in “temporary brittle bone disease,” according to the work of
Marvin Miller. (Emphasis added)
Flawed Medical Consensus that Multiple Fractures in Infants, in the Absence of Known
Accidental Trauma, are Diagnostic of Child Abuse
In 1990 Garcia reported in Journal of Trauma on a series of 33 children brought into
a trauma center with rib fractures, all brought about by blunt trauma. Nearly 70 percent
were from auto accidents, 21.2 percent from child abuse, and 9.1 percent from falls.
Mortality was 42 percent. 72 percent of the children with three rib fractures had internal
chest injuries, such as lung punctures or tears and/or injuries to other internal chest
organs. With four or more rib fractures there were 100 percent internal chest injuries. (1)
By way of explanation, when rib fractures are brought about by severe blunt force,
such as in auto accidents or falls, a significant portion of ribs will be severed and sheared,
the severed pieces acting like spears that are plunged into the deeper chest organs. In the
present series of 30 infants, there was only one report of internal chest injury (pleural
effusions). From a statistical standpoint, this small incidence would have been a virtual
impossibility, had these fractures resulted from violent, inflicted force.
Atrophy of Disuse as Applied to Fetal Bone Development: Spontaneous Fractures Taking
Place during Childbirth or the Neonatal Period, Commonly Attributed to Child Abuse
Atrophy-of-Disuse is a universal principle as applied to human organs, tissues, and
physiology. Bone is no exception. Common examples include bone weakening and rapid
decalcification known to take place during prolonged bed confinement, thereby
predisposing to spontaneous fractures or fractures with minimal trauma. As reported by
Grayev et al, eight children with clubfeet experienced metaphyseal fractures during
physical therapy when their legs were passively manipulated, their legs having been
immobilized for prolonged periods in corrective casts. (4) In studies by Rodriguez et al of
the long bones in newborn infants with congenital muscular dystrophy (with marked
muscle weakening/paralysis), the bones were found to be thin, hypomineralized, and
elongated. In most of the bones there were multiple diaphyseal (shaft area of bone) or
metaphyseal (at ends of bones) fractures or both. (5, 6) A study of rat fetuses that were
curarized (paralyzed) during the later phases of pregnancy revealed marked thinning and
delay in ossification of bone.(7) Conversely, as a matter of common observation, exercise
such as weight lifting strengthens bone as well as muscle, or else stress fractures would
be near universal in more advanced weight training.(8,9)
The following paragraph from the text, Skeletal Tissue Mechanics, by R Martin et
al,(1998) vividly describes the “atrophy of disuse” process as applied to bone:
“It is commonly observed clinically that the intact portions of the fractured bone
become osteoporotic as healing occurs. This generalized osteopenia of the intact
regions, called posttraumatic osteoporosis or posttraumatic bone atrophy, is
2
3. caused by two factors. First, in addition to the healing response, the fracture
causes a remodeling….so that osteonal BMUs riddle the entire cortex with
resorption cavities. The second factor is the removal of mechanical loading from
the fractured bone…If the fracture is well fixed and sufficient loadbearing is
resumed, the resorption spaces will refill and the osteopenia will be
transient.”(10)
In other words, without movement or weight bearing, such as takes place when a
fractured limb is immobilized in a cast, there may be significant decalcification of the
bone; but there will be rapid recalcification once movement, weight bearing, and other
mechanical stresses of daily living are resumed.
With the above material as background, one of the frequent causes of osteopenia with
spontaneous fractures during the perinatal period (shortly before and shortly after birth) is
prematurity. (11-13) As reviewed by Marvin Miller, (12)(2003), premature infants are at
increased risk to develop temporary brittle bone state. It has traditionally been thought
that the primary cause was insufficient calcium and phosphate in the diet of the premature
infant. However, there is emerging evidence that the bone disease of prematurity may be
more of a mechanical issue than one of nutritional mineral deficiency. Miller suggested
that this increased bone resorption in the premature infant compared to the term infant is
secondary to inadequate “bone loading” in the form of fetal muscular movement. During
the last trimester of a full-term pregnancy the fetus is actively kicking and bouncing
against the mother’s uterus. This fetal activity with associated muscle development is the
primary determinant of fetal bone formation, without which the bone remains poorly
ossified, weak, and brittle. (Emphasis added)
It has been shown that preterm infants who receive 5-10 minutes of daily physical
activity, with passive movements of extremities by nurse attendants, realize a 76%
greater gain in bone density by one month of life compared to control premature infants
who receive no physical activity. (8)
M. Miller and T Hangartner have observed a comparable clinical situation referred to
as “temporary brittle bone disease” associated with lack of fetal movement during the last
trimester of pregnancy, in which the baby remains susceptible to spontaneous
fractures with minimal trauma for 6 or more months following birth.(14-
15)(Emphasis added) Risk factors that may lead to reduced fetal movement from limited
uterine confinement include twin or triplet pregnancies, cephalopelvic disproportion,
oligohydramnios (reduced amniotic fluid), large maternal uterine fibroids, or other
maternal structural uterine abnormalities. Fetal structural defects such as clubfoot and
dislocated hips may also result in decreased fetal movement; also short umbilical cords
(16) and depressive-type drugs taken by the mother during pregnancy. (17)
Radiology Interpretations:
It is likely that many cases of metabolic bone disease are being missed in
hospitals for the following reason: In the earlier phases of metabolic bone diseases,
3
4. x-ray studies are of limited value since there must be at least a 30 to 40 percent loss of
bone density (calcification) before there is any detectable reduction of whiteness on the
films,(18-21) a level at which fractures may take place with minimal trauma or ordinary
infant handling, (a physiology unknown to many prosecutors.)
Congenital Rickets from Vitamin D Deficiency
It is well established that there is a re-emergence of vitamin D-deficient rickets
with “an alarming prevalence of low circulating levels of vitamin D in the United States
population, leading to an increased incidence of infant fractures, especially when
premature.” These conclusions were announced by the National Institute of Health (NIH)
following a conference on vitamin D, October 9-10, 2003.(22)
In a study conducted at the Pittsburgh Graduate School of Public Health,
(23)(2007) serum 25-hydroxy vitamin D was measured at 4-21 week gestation and
predelivery in 200 white and 200 black pregnant women and in cord blood of their
neonates. Over 90 percent of women used prenatal vitamins. Women and neonates were
classified as vitamin D deficient at less than 37.5 nmol/LI, insufficient between 37.5 and
80, and sufficient at over 80. At delivery, Vitamin D deficiency and insufficiency
occurred in 29.2% and 54.1% of black women and 45.6% and 46.8 of black neonates,
respectively; 5 % and 42.1% of white women and 9.7% and 56.4% of white neonates
were vitamin D deficient and insufficient respectively. In other words, over 92% of black
neonates and 66% of white neonates were born with grossly deficient or suboptimal
vitamin D levels. It was concluded that black and white pregnant women and neonates
residing in the northern USA are at high risk of vitamin D insufficiency, even when
mothers are compliant with prenatal vitamins. Causes of the reemergence include
reduction in milk intake (milk allergies, lactose intolerance, reduction in vitamin D-
containing fats, and increased use of sun screens (sun acts on skin oils to generate vitamin
D precursors).
An article entitled, “Rickets vs. Abuse: A National and International Epidemic,”
by Kathy Keller and Patrick Barnes,(24)(2008) provided a review of the literature and
four case reports of infants with multiple fractures demonstrating classical x-ray findings
of rickets. Also, in each case vitamin D deficiencies were documented in the mothers.
Classical x-ray findings of congenital rickets include the following:
Washed-out appearance of skull from side view.
Skull sutures widened and irregular.
Pseudo fractures occur in weakened bone with normal infant handling.
Rachitic rosaries: (Bulging irregularities in the growth centers at the anterior ends
of the ribs.)
Irregularities of the paired forearm bones at their endings in the wrists.
Curved diaphyses of leg bones (“bowed legs”) even before walking.
Absence of dense white lines in growth centers of epiphyses, such as at the wrists.
Maternal and infant diet histories are of highest importance in these cases.
4
5. Nutritional rickets has also been described with normal circulating 25-hydroxy
vitamin D attributed to calcium deficiency in infants.(20) Elevated parathormone (PTH)
levels are generally found in these cases.
Infantile Scurvy (Barlow’s Disease)
Infantile scurvy is another possible cause of spontaneous fractures, which may be more
common than generally appreciated. The probability of Barlow’s Disease can be
increased by maternal malnutrition, by hyperemesis gravidarum (excessive vomiting in
pregnancy), by viral or bacterial infections in the mother or the infant. (26) The bones of
infants may be vulnerable to fracture and defective formation before radiological signs
appear. (18-21) Scurvy or subclinical scurvy would contribute to the deficiencies of
proline and lysine hydroxylase (amino acid enzymes) that affect connective tissue
components of bone formation. The hydroxylation (oxidation) of proline and lysine into
procollagen is carried out by the enzyme prolyl hydroxylase, which requires vitamin C
as a cofactor. (27,28) Collagen provides the bone’s tensile strength, comprising 90
percent of bone matrix. Deficiencies in vitamin C would compromise the prolyl
hydroxylase enzyme system, resulting in imperfect bone formation.
Far from being uncommon, vitamin C deficiency does still commonly occur in the
Western World. When people attending a Health Maintenance Organization (HMO) in
Tempe Arizona were tested for plasma vitamin C, it was found to be depleted (between
0.2 and 0.5 mgs/100 ml) in 30 percent and deficient (below 0.2 mgs/100 ml) in 6 percent.
(29) As reviewed by Clemetson, when the human plasma ascorbic acid level falls below
0.2 mg/100 ml, whole blood histamine level is doubled or quadrupled. (30) It has been
shown that bleeding from scurvy results from increased blood histamine, or
histaminemia, which causes separation of endothelial cells from one another in capillaries
and small venules, leading to spontaneous bruising. (31) When these are seen by a
physician, almost always inflicted abuse is erroneously suspected. It follows then that the
diagnosis of non-accidental trauma based on multiple bruises cannot be ethically or
professionally justified without first ruling out scurvy by a plasma vitamin C blood test.
Metabolic Bone Disease and Vitamin K Deficiency
Maternal vitamin K deficiency during pregnancy is a risk factor for hemorrhagic
disease of the newborn (HDN), usually a self-limited disorder taking place within 24 to
72 hours following birth. The primary dietary source of vitamin K is from green, leafy
vegetables. It is for this reason that a maternal dietary history is of highest importance in
adequate evaluation of infant fractures.
Although calcium absorption from the gut into the blood stream is dependent on
vitamin D, it is less well known that vitamin K delivers calcium from the blood into the
bone.(32) Consequently deficiencies of vitamin K in early infancy may be a contributory
cause of metabolic bone disease. Also, bone matrix proteins necessary for normal bone
metabolism are vitamin K-dependent,(33-35) so that vitamin K deficiency in infants can
lead to fractures as well as hemorrhagic disease..
5
6. Osteopenia of Prematurity
As reviewed above under “Atrophy of disuse,” prematurity poses one of the most
common sources of infant fractures. (11-13) This is due to the fact that the fetal kicking
and other vigorous body movements, which are essential for promotion of bone strength
and integrity, are only in their beginning phases when preterm births occur. These
movements are intrinsically necessary for bony maturation, just as they are necessary to
maintain bone strength at all ages following birth.
In Nelson’s Textbook of Pediatrics, 16th Edition, the following quotation is found:
“Osteopenia of prematurity. Very small premature infants with chronic
illnesses often develop a rickets-like syndrome with pathologic fractures and
demineralized bone. There may be associated cholestasis and vitamin D or
calcium malabsorption; urine calcium loss due to diuretics; and poor calcium,
phosphorus, or vitamin D intake, or aluminum toxicity. The treatment of fractures
requires immobilization and administration of calcium and, if needed, phosphorus
(for hypophosphatemia) and vitamin D (not more than 1,000 IU/day unless severe
cholestasis or vitamin D resistance). Appropriate formulas for premature infants
should provide a more optimal intake of calcium, phosphorus, and Vit. D.”(36)
As reviewed by FR Greer:
“Osteopenia of prematurity refers to the hypomineralized skeleton of the
premature infant compared with that of the normal fetal skeleton…..In growing,
low birth-weight infants with birth weight less than 1500 grams (3.3 lbs) and less
than 32 weeks gestational age, it occurs almost without exception. This high
incidence (of hypomineralization) is not surprising considering that 80% if fetal
skeletal mineralization takes place during the last trimester of pregnancy. Thus
one would expect an increasing degree of osteopenia in premature infants with
decreasing gestational age. …Even term infants may have decreased stores owing
to maternal complications such as severe preeclampsia.”(37)
Three reviews of fractures occurring during the first year of life in premature
infants (38-40) found that rib fractures often remain undetected and are only discovered
on x-rays taken for other reasons. In one series, clinical suspicion of fractures was
documented prior to ordering the radiographs in only 3 of the 19 (16%) infants.(41)
Hence the true incidence of fractures in infants born prematurely remains unknown, but it
probably is much more common tan reported in the literature.
Timing of Fractures
In court cases involving multiple fractures in which parent and/or caretaker have
been accused of child abuse, the dating or timing of the fracture often plays a critical role.
6
7. As reviewed by Amir et al,(11) from 1977 to 1984, 973 premature infants were
admitted to the neonatal intensive care unit of Beilinson Medical Center, Petah Tiquva
(Isreal). Among those who survived over 6 months, 12 suffered from fractures that
appeared during their hospitalization between ages 24 and 60 days. All of these were
without clinical signs. All were diagnosed on routine chest x-rays. Callus was always
present when first diagnosed. In six instances angulation was present, but there were no
instances of separation or dislocation in the fractures. According to the authors, fractures
usually occur a few weeks after birth, and are almost always pathologic, the most
common cause being metabolic bone disease.
According to N. Bishop, who observed a somewhat different timing, fractures due
to osteopenia of prematurity and preterm rickets occur typically from 10 weeks age and
usually stop before 6 months.(39)
In one of the earliest prospective studies of the clinical course of fractures and
rickets in very low birth weight infants (less than 1,500 grams) by WH Koo et al, (13) 78
infants were enrolled solely on the criteria of birth weight <1,500 grams. There was a
distribution of 82 fractures in 19 infants in the study. 73 fractures (89%) originated
during the course of hospitalizations ranging from 32 to 131 days. Clinical suspicion was
documented prior to ordering the radiographs in only three of the 19 infants (16%). It was
further determined that physical therapy was the source of some of the fractures.
Fractures from congenital rickets, when followed serially on radiographs, showed
complete resolution beyond six months after birth.
Conclusions and Recommendations:
The Jenny report in 2006, which established a standard for the differential
diagnosis of multiple fractures in infants and children, might justifiably be considered a
major landmark in medical history. Since the publication of this report, it has been
incumbent on physicians to rule out various forms of metabolic bone disease before
diagnosing inflicted child abuse directed against parent or caretaker. In my opinion,
failure to do this must be considered substandard medical practice, bringing disrepute on
the medical profession.
According to the time-honored principle of “considered innocent until proven
guilty,” appropriate medical evaluation of multiple fractures would require a formal
listing of a differential diagnosis and appropriate laboratory tests. In addition to routine
chemistries and blood counts, blood tests should include 25-hydroxy vitamin D, alkaline
phosphatase, parathormone, calcium, phosphorus, serum histamine, plasma vitamin C,
and tissue exams for osteogenesis imperfecta. These tests should be performed
immediately on finding of fractures, as later tests might be irrelevant. A careful medical
history of the mother’s diet and vitamin supplements during pregnancy and of the infant’s
diet and supplements following birth are of paramount importance. Lacking these criteria,
diagnosis of inflicted child abuse cannot be justified.
7
8. References
1. Garcia V, Gotschall C, Eichelberger M, Bowman L. Rib fractures in children: a marker
of severe trauma, J Trauma. 1990; 30(6):695-700.
2. As reported by Jenny C, Committee on Child Abuse and Neglect, in “Evaluating
infants and young children with multiple fractures,” Pediatrics, 2006 Sept; 118(2):1299-
1333.
3. Qutob S, Dixon S.J., and Wilson, J.X. Insulin stimulates vitamin C recycling and
ascorbate accumulation in osteoblastic cells, Endocrinology, 1998; 139(1):51-56.
4. Grayev A. Metaphyseal fractures mimicking abuse during treatment for clubfoot.
Pediatr Radiol, 2001; 31:559-563.
5, Rodriguez J, Garcia A, Palacios J et al. Changes in long bone due to fetal immobility
caused by neuromuscular disease. J Bone and Joint Surg, Aug., 1988; 70-A:1052-1060.
6. Rodriguez, JI, Palacios, J, Garcia-Alix A, Pastor I, Paniagua R. Effects of
immobilization on fetal bone development. A morphometric study in newborns with
congenital neuromuscular diseases with intrauterine onset. Calcific Tissue Intern., 1988;
43:335-339.
7. Rodriguez J, Palacios J, Ruiz A et al. Morphologic changes in long bone development
in fetal akinesia deformation sequence: an experimental study in curarized rat fetuses.
Teratology, 1992; 45:213-221.
8. Moyer-Mileur U, Brunstetter V, McNaught TP, et al. Daily physical activity increases
bone mineralization and growth in preterm very low weight infants. Pediatrics, 2000;
106:1088-1092.
9. Hangartner, TH. Osteoporosis due to disuse. Physical Medicine Rehabilitation, Clinics
of North America, 1995; 6:579-594.
10. Martin R, Burr D, Sharkey, N. In: Skeletal Tissue Mechanics, New York: Springer,
1998: 75.
11 Amir J, Katz K, Grunebaum M, et al. Fractures in premature infants. J Pediatr
Orthop, 1988; 8:41-44.
12 Dabezies E and Warren P. Fractures in very low birth weight infants with rickets.
Clinical Orthopaedics and Related Research, 1997; 335:233-239.
13 Koo W, Sherman R, Succop P et al. Fractures and rickets in very low birth weight
infants: conservative management and outcome. J Pediatr Orthop, 1989; 9:326-330.
14. Miller ME, Hangartnes T. Temporary brittle bone disease: associated with decreased
fetal movement and osteopenia. Calcif Tissue Int., 1999:137-143.
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