Disclosures: Sarah E. Williams, MD: No financial relationships or conflicts of interest

Case Description: A 29-year-old male with no significant past medical history sustained an 85% total body surface area burn from a house fire. The patient had a prolonged, complex hospitalization with three and a half months in the ICU, where he experienced severe nausea. Hypercalcemia developed two months after admission. After extensive evaluation, the etiology was determined to be immobilization induced hypercalcemia. Despite treatment with low calcium dialysate, calcium levels remained elevated. After six weeks with hypercalcemia, he was found to have restricted elbow extension. Initial radiographs were negative for ossification, but the clinical picture was most consistent with heterotopic ossification. The patient was admitted to inpatient rehabilitation where calcium remained elevated and range of motion in elbows continued to worsen despite therapy. Intravenous Pamidronate was administered for management of hypercalcemia and prevention of advancement of heterotopic ossification.

Setting: Inpatient Rehabilitation Unit

Patient: 29-year-old male with 85% total body surface area burns Assessment/

Results: Forty-eight hours after treatment with Pamidronate, the patient’s serum calcium level normalized. Clinical progression of his heterotopic ossification in bilateral elbows halted after treatment. Additionally, his nausea improved dramatically after other interventions had failed. Range of motion in his elbows then improved progressively with intensive therapy. Radiographs before discharge confirmed heterotopic ossification of bilateral ulno-humeral joints.

Discussion: While the mechanism of heterotopic ossification is poorly understood, this presentation and course suggest that elevated levels of extracellular calcium contribute to the progression of heterotopic ossification and that normalization of serum calcium with bisphosphonate administration may slow or stop mineralization. To our knowledge, these two syndromes of immobilization induced hypercalcemia and heterotopic ossification have not been described concurrently, but they may be co-occurring in other rehabilitation patients that are severely immobilized.

Conclusion: Calcium is a known promoter of osteogenesis, and prompt recognition and treatment of immobilization induced hypercalcemia may help to arrest or even prevent heterotopic ossification.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/immobilization-induced-hypercalcemia-and-heterotopic-ossification-in-a-burn-patient/