Disclosures: Chong-Tae Kim, MD, PhD: No financial relationships or conflicts of interest

Case Diagnosis: Subperiosteal hematoma secondary to Vitamin C deficiency

Case Description or Program Description: A 14-year-old male with a past medical history of diplegic cerebral palsy (CP), Gross Motor Function Classification Scale III, presented to an ER with chief complaint of poorly localized progressive pain (likely at hip area) and immobility for several months. He had received 400 units of onabotulinumtoxin A to his hip adductors and hamstrings 4 months prior to the ER visit with minimal pain relief. In the ER, physical examination were noncontributory except pain of the proximal legs. X-rays for the bilateral lower extremity showed diffuse demineralization without fracture or dislocation. Pelvis MRI was notable for large multifocal subperiosteal hematomas along the anterior iliac bones bilaterally. Comprehensive coagulation studies were all negative. He had a limited preferred diet without fruits or vegetables. Additionally he had episodes of gum bleeding. He was empirically given vitamin C (Vit C) 125 mg three times a day while waiting for his Vit C level, which came back “undetectable.” After receiving Vit C for two days, his pain improved and was noted to have increased lower extremity movement. On hospital day eight, he underwent drainage and aspiration of bilateral subperiosteal hematomas under ultrasound guidance. As the pain resolved, he then started to regain his mobility function.

Setting: University Pediatric Hospital

Assessment/Results: Vitamin C deficiency caused subperiosteal hematomas of the bilateral iliac bone and consequently resulted in progressive hip pain and immobility in a child with CP. Aggressive Vitamin C replacement and drainage relieved the pain and immobility.

Discussion (relevance): If patients with CP present with progressive worsening pain and x-ray studies are negative, further investigation (such as MRI) is suggested. Diet history should always be considered because Vit C deficiency can be a cause of musculoskeletal pain in children with chronic disability.

Conclusions: A patient with diplegic CP and Vit C deficiency presented with progressive hip pain and immobility. Subperiosteal hematomas of the bilateral iliac bone were found on MRI to be the source of the pain. It was concluded that the hematomas developed secondary to Vit C deficiency. The patient’s pain and immobility resolved with aggressive Vit C replacement and hematoma drainage.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/vitamin-c-deficiency-unusual-cause-of-hip-pain-in-a-child-with-cerebral-palsy-a-case-report/