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ENDGAMES: Jenny S Radesky and Naomi F Sugar Femur fracture in an infant BMJ 2009; 338: b1583 [Full text]

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Investigating Fractures in Children

Michael D Innis   (19 May 2009)

Investigating Fractures in Children 19 May 2009
Michael D Innis, Medicolegal Consultant Home Send response to journal: Re: Investigating Fractures in Children	Editor, "Bruises of the thighs and even fracture of the femur have been recorded as arising from the gentle act of diapering a scorbutic infant" [1] and "old fractures can be discovered in infants only after radiographs are obtained for reasons other than an assessment of OI, "[2]; In brief, the two main reasons for a femoral or any fracture in an infant are: 1. Abnormality or insufficiency of collagen resulting from deficiencies of Vitamin C, Vitamin D or Copper, and the genetic abnormality Osteogenesis Imperfecta.[3] 2. Inadequacy of mineralization of collagen from a deficiency or abnormality of Vitamin K [4]. The History should include 1. Recent Vaccination - since vaccination may cause a precipitous fall in serum levels of Vitamin C in some children [5,6] The Investigations should include: 1. Complete blood count since anaemia is frequently associated with malabsorption of essential Vitamins and minerals. 2. Coagulation Screen to detect a deficiency/abnormality of Vitamin K a. Prothrombin Time b, Protein Induced by Vitamin K Absence/Abnormality (PIVKA) c. APTT d. Liver Function Tests AST, ALT and Gamma GT, e. Under-carboxylated Osteocalcin 3. Tests for Vitamin C deficiency a. Measurement of intracellular vitamin C levels in human lymphocytes by reverse phase high performance liquid chromatography (HPLC). [7] b. Serum Tryptase [8] c. Serum Histamine. "Even mild ascorbate deficiency is associated with high blood histamine levels"[9] d. Serum Vitamin C 4. Tests to detect malabsorption and Vitamin D deficiency a. Serum Albumin ,Total proteins Calcium and Phosphorus. b Serum 25-hydroxy-vitamin D concentration c. Serum Alkaline Phosphatase. 5. Skin Biopsy and DNA tests and Serum Copper if Osteogenesis Imperfecta is suspected.[3,10] Conclusion. From an analysis of more than three dozen similar cases of children with fractures I conclude that the femoral fracture described in this case was the result of either Vitamin C or K deficiency or a combination of both. The results of the blood tests for these two deficiencies should confirm the diagnosis. References: 1. Clemetson CAB. Vitamin C PDF file 1989 Boca Raton.Fla CRC Press Vol 2 p 71 2. Plotkin H, Pattekar MA. Caddiarelli AA. Osteogenesis Imperfecta http://emedicine.medscape.com/article/947588-overview 3. Jenny C, Committee on Child Abuse and Neglect. Evaluating infants and young children with multiple fractures. Pediatrics 2006 Sep;118 4 Innis MD. Vitamin K Deficiency Disease Jour Orthomol Med 2008;23:15-20 5. Clemetson CAB. Is It "Shaken Baby" or Barlow's Disease Variant? Jour Amer Phys & Surg.2004;78-80 6. Kalokerinos A Every Second Child. Foreword by Linus Pauling. Keating Publishing Inc 1981. 7. Emadi-Konjin,P,.,Verjee,Z, Levin AV,,,Adeli K..Clin Biochem. 2005 May;38(5):450-6. 8, Zinka B, Rauch E, Buettner A, Ruëff F, Penning R. Unexplained cases of sudden infant death shortly after hexavalent vaccination. Vaccine. 2006; Jul 26;24(31-32):5779-80. 9. Clemetson, CAB. Histamine and ascorbic acid in human blood, J. Nurr.,1980 110, 662. 10. Paterson CR, Burns J, McAllion SJ. Osteogenesis imperfecta: the distinction from child abuse and the recognition of a variant form. Am J Med Genet. 1993 Jan 15;45(2):187–192. Competing interests: I have given Expert testimony in similar cases and been paid for my services.