Multi-trauma secondary to hypocalcaemia-induced seizure: A case report

Abstract

IntroductionFractures are known sequelae of seizures. We present a young male with bilateral acetabula and surgical neck of humerus (SNOH), right neck of femur (NOF) and thoracolumbar fractures in the context of a hypocalcaemic seizure secondary to severe malnutrition, secondary hyperparathyroidism and vitamin D deficiency. The authors believe that numerous severe injuries in a single patient secondary to seizure are extremely rare and have not been seen in the literature.Case reportA 25-year-old male presented to A&E following a collapse. He described limited movement and pain in all four limbs and collateral history described a generalised tonic–clonic seizure. XR and CT identified pelvic, femoral and humeral fractures, as well as compression fractures of T11, T12 and L1 vertebrae. His pelvic, femoral and SNOH fractures all required ORIF with intra-operative biopsy revealing abnormal bone quality. His spinal fractures did not require management.His young age and severe injuries prompted endocrinology and neurological evaluation. These revealed severe malnutrition secondary to behavioural and dietary factors with severe hypocalcaemia, secondary hyperparathyroidism and vitamin D deficiency. His metabolic and nutritional deficits were replaced intravenously and orally and his seizure attributed to hypocalcaemia.Discussion and conclusionClinical suspicion for fractures should be high as the rate of fracture following seizure is approximately 6% [1]. Close evaluation and tertiary survey should be completed as missed musculoskeletal injury has been reported to be over 10% [2] and pre-existing medical and social risk factors may increase the incidence of these injuries [3–4].Given the young man's presentation, a high clinical suspicion was held for an underlying syndrome such as osteomalacia. Secondary to early aggressive treatment, a biopsy performed was non-diagnostic and features of osteomalacia were not present. Due to the potential consequences of a seizure, the authors recommend individuals who present with seizure or collapse be thoroughly examined and investigated to ensure no co-existing injury or pathology.

Total Hip Arthroplasty for the Sequelae of Femoral Neck Fractures in the Pediatric Patient

“…Although we provide the first reported case of bilateral femoral neck fractures caused by a seizure in a pediatric patient, there are several previous reports of such an injury with a similar mechanism in adults [48][49][50][51][52]. The reported incidence of any type of fracture after a generalized tonic-clonic seizure episode is 1.1% [48,53,54]. Most of these fractures involve the proximal humerus [53], and the incidence of femoral neck fractures is currently unknown due to its rarity.…”

Management and Outcomes of Bilateral Acetabular Fractures: A Critical Review of the Literature

“…Follow-up was reported in 72% (34/47) of the cases with a range of 1.5–56 months, (mean 19.8 months) [ 5 – 16 , 18 – 28 , 30 , 32 – 41 ]. The most common MOI was high energy in 49% (23/47; male/female ratio (M/F) = 3.6/1) [ 8 , 12 , 13 , 15 , 20 , 25 , 26 , 29 , 30 , 33 , 34 , 36 , 38 , 39 ], followed by seizures in 45% (21/47; M/F = 3.2/1) [ 6 , 9 – 11 , 14 , 16 , 17 , 19 , 21 – 24 , 27 , 31 , 32 , 35 , 37 , 40 , 41 ], and lastly by insufficiency fractures secondary to osteoporosis 6% (3/47) (Table 2 ) [ 5 , 7 , 28 ]. High-energy injuries were secondary to RTAs (70%; 16 patients) [ 12 , 13 , 15 , 20 , 26 , 29 , 30 , 33 , 34 ], falls from height (13%; 3 patients) [ 8 , 38 , 39 ], direct blows (9%; 2 patients) [ 25 , 30 ], crush injury (4%; 1 patient) [ 34 ], and unknown mechanism (4%; 1 patient) [ 18 ].…”

“…High-energy injuries were secondary to RTAs (70%; 16 patients) [ 12 , 13 , 15 , 20 , 26 , 29 , 30 , 33 , 34 ], falls from height (13%; 3 patients) [ 8 , 38 , 39 ], direct blows (9%; 2 patients) [ 25 , 30 ], crush injury (4%; 1 patient) [ 34 ], and unknown mechanism (4%; 1 patient) [ 18 ]. Mean age was 38 years (range 15–82) for the high-energy group [ 8 , 12 , 13 , 15 , 18 , 20 , 25 , 26 , 29 , 30 , 33 , 34 , 36 , 38 , 39 ], 55 years (range 13–84) for the seizure group [ 6 , 9 – 11 , 14 , 16 , 17 , 19 , 21 – 24 , 27 , 31 , 32 , 35 , 37 , 40 , 41 ] and 47 years (range 23–70) for the insufficiency fractures group [ 5 , 7 , 28 ].…”

“…Overall, there were 58% excellent/good outcomes with complete functional recovery and independent mobilization [5, 7, 9, 10, 13, 15-18, 22, 25, 26, 28, 31, 33-35, 38-40], 22% fair with limited range of motion of both hips and moderate pain [6,8,23,30,32,34,36,37], and 20% poor outcomes with limited activity and walking ability (Table 7) [11,12,14,20,21,24,34]. According to injury group, excellent/good outcomes were reported in 60% of the high-energy patients [13,15,18,25,26,33,34,38,39], 47% of the seizures patients [9,10,16,17,22,31,35,40], and in 100% of the insufficiency fracture group [5,7,28].…”

“…Those were reported in 89% of the cases (42/47 cases) [5-14, 16, 17, 19-24, 26-34, 36-41]. The most common associated injuries were upper limb injuries (26%) [8,10,13,17,19,31,32,34,37,39], pelvic fractures (23%) [7,11,12,34,36,38,39,41], femoral fractures (19%) [10,16,31,32,34,38], spine injuries (14%) [10,27,30,31,34], acetabular fracture associated with hip dislocation (23%)…”