Working Diagnosis:
Right-sided distal tibial shaft fracture due to underlying pediatric osteoporosis

Treatment:
Week 0: Patient was placed in a long leg cast for 4 weeks and was non-weight-bearing.
Week 4: Patient was transitioned to a short leg cast for an additional 2 weeks of non-weight-bearing.
Week 6: Patient was transitioned to a CAM boot and was able to slowly advance to weight bearing as tolerated and begin basic home exercises.
Week 10: Patient was able to transition out of the CAM boot and begin full weight bearing as tolerated.

Outcome:
At 6 weeks out, patient was able to begin swimming again, initially without kicking, flip turns, starts, or jumping maneuvers. At 10 weeks out, he started home exercises with his swim coach including ankle and knee ROM along with core strengthening. At 15 weeks out, he was able to return to full activity as tolerated with no restrictions.
At week 18, he swam in the state meet for the first time.
Recommended continued vitamin D and calcium supplements along with good nutrition and repeat DXA scan in 1 year to monitor bone density.
Encouraged continued follow up with pediatric gastroenterology for treatment of Crohn's disease.

Author's Comments:
Patient qualifies for diagnosis of pediatric osteoporosis due to Z-score of the AP spine less than -2.0 along with history of multiple fractures due to very minimal trauma. His current fracture was likely due to secondary osteoporosis from inflammatory bowel disease and history of steroid use. Osteoporosis is found in 18-42% of individuals with inflammatory bowel disease. The pathogenesis involves both chronic inflammation and malabsorption. Proinflammatory cytokines released in inflammatory bowel disease increase the ratio of RANK ligand, which activates osteoclasts, to osteoprotegerin, which blocks osteoclasts, therefore leading to an increase in bone resorption. In Crohn's disease specifically, patients have a risk ratio of 1.7 compared to normal individuals for overall fracture risk.

References:
Hyun Jin Oh, Kum Hei Ryu, Bum Joon Park, Byung-Ho Yoon. Osteoporosis and Ostoeporotic Fractures in Gastrointestinal Disease. Journal of Bone Metabolism 2018. 213-217. 24 November 2018.
Tenforde, Adma S., Barrack, Michelle T., Nattiv, Aurelia., Fredericson, Michael. Parallels with the Female Athlete Triad in Male Athletes. Springer International Publishing. 26 October 2015.
Boot, Annemieke M., de Ridder, Maria A. J., Pols, Huibert A. P., Krenning, Eric P., de Muinck Keizer-Schrama, Sabine M. P. F. Bone Mineral Denisty in Children and Adolescents: Relation to Puberty, Calcium, Intake, and Physical Activity. The Journal of Clinical Endocrinology and Metabolism, Volume 82, Issue 1, 57-62. 01 January 1997.
Special thanks to: Ashley Yelinek, DO and Whitney Courtney, DO

Return To The Case Studies List.