LETTER
TO THE
EDITOR
Osteogenesis Imperfecta and Rib Fractures in Infancy To the Editor: I read with some concern the report of Greeley et al.1 They found no rib fractures in infants with osteogenesis imperfecta (OI) in the first year of life. They concluded that OI was unlikely to be the cause of unexplained rib fractures at this age. One difficulty is that in OI and other bone disorders rib fractures in the first year of life are almost always asymptomatic. The original x-rays were not reviewed by Greeley and colleagues, and it is not clear from their report how many chest x-rays were obtained at the relevant time. In known cases of OI, physicians make great efforts to minimize the number of x-rays requested to reduce radiation exposure. In contrast, when child physical abuse is suspected, very full skeletal surveys are undertaken. As rib fractures are asymptomatic it is not surprising that they are most frequently found in the latter situation. Although the most common presentation of OI is a symptomatic diaphyseal fracture, rib fractures do occur in known cases and may lead to initial misdiagnosis.2–5 That rib fractures may occur spontaneously in OI is illustrated by Figure 1, which shows an infant, later identified as having OI type III, on the day of birth. Multiple rib fractures of various ages had clearly occurred in utero. A second difficulty with the report by Greeley et al1 is the implication that the differential diag-
FIGURE 1. Multiple healing rib fractures on day of birth in a boy later diagnosed as having osteogenesis imperfecta type III.
nosis of unexplained rib fractures is between OI and child physical abuse. OI is not the only bone disorder to cause spontaneous rib fractures. These are found in a wide range of metabolic disorders including osteopathy of prematurity,6,7 vitamin D deficiency,8,9 copper deficiency,10 and other unexplained disorders.11,12 It is important to be aware that rib fractures during infancy have a wide differential diagnosis.
4. Paterson CR, McAllion SJ. Classical osteogenesis imperfecta and allegations of nonaccidental injury. Clin Orthop Relat Res. 2006;452:260–264. 5. Kocher MS, Dichtel L. Osteogenesis imperfecta misdiagnosed as child abuse. J Pediatr Orthop B. 2011;20:440–443. 6. Wei C, Stevens J, Harrison S, et al. Fractures in a tertiary neonatal intensive care unit in Wales. Acta Paediatr. 2012;101:587–590. 7. Lucas-Herald A, Butler S, Mactier H, et al. Prevalence and characteristics of rib fractures in ex-preterm infants. Pediatrics. 2012;130:1116–1119. 8. Rossier A, Arvay N, Blanchet G, et al. The fractures of rachitic children. J Radiol Electrol Med Nucl. 1963;44:377–378. 9. Chapman T, Sugar N, Done S, et al. Fractures in infants and toddlers with rickets. Pediatr Radiol. 2010;40: 1184–1189. 10. Paterson CR, Burns J. Copper deficiency in infancy. J Clin Biochem Nutr. 1988;4: 175–190. 11. Tsujii M, Hirata H, Hasegawa M, et al. An infant with unexplained multiple rib fractures occurring during treatment in a neonatal intensive care unit. Turk J Pediatr. 2008;50:377–379. 12. Paterson CR, Monk EA. Clinical and laboratory features of temporary brittle bone disease. J Pediatr Endocr Metab. 2013, doi: 10.1515/jpem-2013-0120.
Colin R. Paterson, DM Formerly Department of Medicine University of Dundee, Dundee, UK
REFERENCES 1. Greeley CS, Donaruma-Kwoh M, Vettimattam M, et al. Fractures at diagnosis in infants and children with osteogenesis imperfecta. J Pediatr Orthop. 2013;33: 32–36. 2. Gahagan S, Rimsza ME. Child abuse or osteogenesis imperfecta: how can we tell? Pediatrics. 1991;88:987–992. 3. Minnis H, Ramsay R, Ewije P, et al. Osteogenesis imperfecta and non-accidental injury. Br J Psychiatr. 1995;166:824–825.
The author declares no conflict of interest.
e12 | www.pedorthopaedics.com
J Pediatr Orthop
Volume 34, Number 5, July/August 2014
TO THE
EDITOR
Osteogenesis Imperfecta and Rib Fractures in Infancy To the Editor: I read with some concern the report of Greeley et al.1 They found no rib fractures in infants with osteogenesis imperfecta (OI) in the first year of life. They concluded that OI was unlikely to be the cause of unexplained rib fractures at this age. One difficulty is that in OI and other bone disorders rib fractures in the first year of life are almost always asymptomatic. The original x-rays were not reviewed by Greeley and colleagues, and it is not clear from their report how many chest x-rays were obtained at the relevant time. In known cases of OI, physicians make great efforts to minimize the number of x-rays requested to reduce radiation exposure. In contrast, when child physical abuse is suspected, very full skeletal surveys are undertaken. As rib fractures are asymptomatic it is not surprising that they are most frequently found in the latter situation. Although the most common presentation of OI is a symptomatic diaphyseal fracture, rib fractures do occur in known cases and may lead to initial misdiagnosis.2–5 That rib fractures may occur spontaneously in OI is illustrated by Figure 1, which shows an infant, later identified as having OI type III, on the day of birth. Multiple rib fractures of various ages had clearly occurred in utero. A second difficulty with the report by Greeley et al1 is the implication that the differential diag-
FIGURE 1. Multiple healing rib fractures on day of birth in a boy later diagnosed as having osteogenesis imperfecta type III.
nosis of unexplained rib fractures is between OI and child physical abuse. OI is not the only bone disorder to cause spontaneous rib fractures. These are found in a wide range of metabolic disorders including osteopathy of prematurity,6,7 vitamin D deficiency,8,9 copper deficiency,10 and other unexplained disorders.11,12 It is important to be aware that rib fractures during infancy have a wide differential diagnosis.
4. Paterson CR, McAllion SJ. Classical osteogenesis imperfecta and allegations of nonaccidental injury. Clin Orthop Relat Res. 2006;452:260–264. 5. Kocher MS, Dichtel L. Osteogenesis imperfecta misdiagnosed as child abuse. J Pediatr Orthop B. 2011;20:440–443. 6. Wei C, Stevens J, Harrison S, et al. Fractures in a tertiary neonatal intensive care unit in Wales. Acta Paediatr. 2012;101:587–590. 7. Lucas-Herald A, Butler S, Mactier H, et al. Prevalence and characteristics of rib fractures in ex-preterm infants. Pediatrics. 2012;130:1116–1119. 8. Rossier A, Arvay N, Blanchet G, et al. The fractures of rachitic children. J Radiol Electrol Med Nucl. 1963;44:377–378. 9. Chapman T, Sugar N, Done S, et al. Fractures in infants and toddlers with rickets. Pediatr Radiol. 2010;40: 1184–1189. 10. Paterson CR, Burns J. Copper deficiency in infancy. J Clin Biochem Nutr. 1988;4: 175–190. 11. Tsujii M, Hirata H, Hasegawa M, et al. An infant with unexplained multiple rib fractures occurring during treatment in a neonatal intensive care unit. Turk J Pediatr. 2008;50:377–379. 12. Paterson CR, Monk EA. Clinical and laboratory features of temporary brittle bone disease. J Pediatr Endocr Metab. 2013, doi: 10.1515/jpem-2013-0120.
Colin R. Paterson, DM Formerly Department of Medicine University of Dundee, Dundee, UK
REFERENCES 1. Greeley CS, Donaruma-Kwoh M, Vettimattam M, et al. Fractures at diagnosis in infants and children with osteogenesis imperfecta. J Pediatr Orthop. 2013;33: 32–36. 2. Gahagan S, Rimsza ME. Child abuse or osteogenesis imperfecta: how can we tell? Pediatrics. 1991;88:987–992. 3. Minnis H, Ramsay R, Ewije P, et al. Osteogenesis imperfecta and non-accidental injury. Br J Psychiatr. 1995;166:824–825.
The author declares no conflict of interest.
e12 | www.pedorthopaedics.com
J Pediatr Orthop
Volume 34, Number 5, July/August 2014
