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Low Vitamin D Levels are Associated With Need for Surgical Correction of Pediatric Fractures

Minkowitz, Barbara MD; Cerame, Barbara MD; Poletick, Eileen RN, DNP; Nguyen, Joseph T. MPH; Formoso, Nicole D.; Luxenberg, Sherri L. BA; Lee, Ben H. MD, MPH, MSCR; Lane, Joseph M. MDMorris-Essex Pediatric Bone Health Group

Journal of Pediatric Orthopaedics: January 2017 - Volume 37 - Issue 1 - p 23–29
doi: 10.1097/BPO.0000000000000587

Background: There is growing concern over the relationship between the severity of pediatric fractures and low vitamin D [25-hydroxyvitaminD (25(OH)D)] status.

Objective: Compare 25(OH)D levels and lifestyle of children with fractures to nonfracture controls to determine if 25(OH)D levels are associated with fractures and if there is a 25(OH)D fragility fracture threshold.

Methods: Pediatric fracture and nonfracture controls were included. Bone health survey and medical record data were analyzed. Fractures were categorized using the Abbreviated Injury Scale (AIS). AIS 3 fractures were identified as fractures that required surgical intervention. Univariate and multivariable ordinal regression analyses were performed to identify potential risk factors for increased fracture severity.

Results: A total of 369 fracture patients and 662 nonfracture controls aged 18 years and younger were included. Both groups’ 25(OH)D levels were comparable. 25(OH)D was 27.5±8.9 in the fracture group compared with 27.4±9.1 ng/mL in nonfracture controls (P=0.914). AIS 3 fractures had lower 25(OH)D levels (24.6±9.3 ng/mL) versus AIS 1 and 2 (30.0±10.8 and 28.3±8.4, respectively, P=0.001). Univariate correlations for AIS severity were found with age (P=0.015) and outdoor playtime (P=0.042). Adjusted odds ratios for 25(OH)D levels <12 ng/mL was 55.4 (P=0.037), 25(OH)D between 12 and 20 ng/mL was 6.7 (P=0.039), 25(OH)D between 20 and 30 ng/mL was 2.8 (P=0.208), and 25(OH)D between 30 and 40 was 1.7 (P=0.518).

Clinical Relevance: Occurrence of a pediatric fracture was not associated with 25(OH)D levels in our study. However, children with lower vitamin D levels were found to be at higher risk for more severe fractures. Early evidence suggests that the target serum level for 25(OH)D should be at least 40 ng/mL in patients less than 18 years of age as the relative risk of more severe fractures increased as 25(OH)D levels decreased <40 ng/mL.

Level of Evidence: Level III.

*Pediatric Orthopedic Surgery

Pediatric Endocrinology, Goryeb Children’s Hospital at Atlantic Health System, Morristown, NJ

Hospital for Special Surgery, New York, NY

J.T.N. was supported in part by funds from the Clinical Translational Science Center (CTSC) and the National Center for Advancing Translational Science (NCATS). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NCATS based in Rockville, MD.

J.M.L. is a consultant for the following: Graftys, Kuros, Bone Therapeutics, and CollPlant. The remaining authors declare no conflicts of interest.

Morris-Essex Pediatric Bone Health Group: Barbara Minkowitz, MD; Tim U. Leier, MD; Martin L. Cohen, MD; William L. Lupatkin, MD; Suhaib G. Nashi, MD; Tamara McCluskey, DO; Meera Gupta, MD; Maria Gatoulis, MD; Christian Canzoniero, MD; Rajesh Raman, MD; Michael D. Nathan, DO; Zehra Z. Aygen, MD; Kadri M. Aygen, MD; Andrea G. Katz, MD; Susan S. Barasch, MD; Bonita Gillard, MD; Donna Koward, MD; Karen Brandstaedter, MD; Sarah Kramer, MD; Lorin Levin, MD; Andrea Ploshnick, MD; Jeffrey Eng, MD; Jessica S. Haines, APN; Nancy Montville, APN; Nicole D. Formoso; Sherri L. Luxenberg; Steven Moskowitz, MD; Kathleen L. Chin, MD; Denise Visci, MD; Eunhee Shih, MD; Richard Lander, MD; Yanina Meshko, MD; Ami Mehta, MD; Hemant Kairam, MD; Teresa Manocchio, DO; Maureen Baxley, MD; Francisco Silva, MD; Sandra R. Voremberg, MD; Jennifer Shaw-Brachfeld, MD; Valerie Tom, MD; Margot Kerrigan, MD; Stuart Slavin, MD; Maria C. Cerdena, MD; John S. Freiheiter, MD; Julio C. Guerra, MD; Ricki L. Gottlieb, MD; Beth Gelman, MD; Elena Shteynberg, MD; Frank A. Sinatra, MD; John Visci, MD; Patricia Peng, DO; Jaclyn Brittman, DO; Marisa Farinella, DO; Lior Fusman; Renee Eng; Jonathan Chevinsky; Samantha Easton; Connor Jordan; Scott Musial.

Reprints: Barbara Minkowitz, MD, Pediatric Orthopedic Surgery, Goryeb Children’s Hospital at Atlantic Health System, 100 Madison Avenue, Morristown, NJ 07960. E-mail:

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