Multiple fractures in children without trauma warrant a closer look

Fractures are common in children, but multiple fractures in the absence of severe trauma may warrant a more thorough evaluation.

Fractures are common in children, but multiple fractures in the absence of severe trauma may warrant a more thorough evaluation.

An estimated 25% to 40% of girls and 30% to 50% of boys sustain a single fracture by adulthood. An estimated 16% to 25% have more than one fracture. The age range where fractures happen the most is between ages 11 to 12 for girls and 13 to 14 for boys.

“Unfortunately, some kids will get injured and fractures are common in childhood. The question is when do the fractures point to something more serious,” said Daniel R. Bachman, M.D., a pediatric orthopedic surgeon with Norton Children’s Orthopedics of Louisville, affiliated with the UofL School of Medicine. “Fortunately, there is a straightforward algorithm for deciding when we need to take a closer look.”

If a child has a vertebral compression fracture or two or more long-bone fractures unrelated to severe trauma by age 10, or three or more long-bone fractures by 19, further bone health evaluation is warranted.

“This is especially true if the fractures were from low-trauma falls, such as tripping and falling, instead of falling from a higher height like monkey bars,” Dr. Bachman said.

Bone fragility in children can arise from a primary bone disorder. The most common is osteogenesis imperfecta (OI), a family of genetic disorders affecting collagen levels. Other primary conditions leading to bone fragility include idiopathic juvenile osteoporosis, and Ehlers-Danlos syndrome, a connective tissue disorder.

Secondary conditions that can affect a child’s bones include vitamin or nutritional deficiencies, Duchenne muscular dystrophy, chronic inflammatory conditions, endocrine abnormalities, leukemia, renal disease and bone deficiencies resulting from medication.

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Evaluation of a child to identify risk factors leading to bone fragility includes a history and clinical examination. Calcium and phosphate homeostasis is assessed by measuring serum calcium, phosphate, creatinine, parathyroid hormone and urinary calcium excretion, which has been associated with increased fracture risk.

Evaluation of vitamin D should be done by measuring 25-hydroxyvitamin D. Levels above 50 nanomoles per liter are considered optimal in a child with a history of fractures.

A standing lateral spine radiograph can identify vertebral height loss, which can result from bone fragility. Vertebral height loss of 20% or higher is considered significant.

Bone mineral density should be tracked over time and should be reported as a Z score compared with age- and gender-matched normative data.

If a child has a history of bone fractures, bone pain or a bone mineral density Z score less than minus 2, referral to a specialist is indicated.

First-line treatment for children with bone density issues involves ensuring adequate calcium and vitamin D intake, weight-bearing exercise, and minimizing exposure to activities that might risk further fractures.

Second-line treatment could require pharmacological intervention. Bisphosphonates are the most commonly used medication for bone fragility in children, though they usually are reserved for moderate to severe cases.

Many health care providers in the pediatric community are worried that lifestyle factors such as worsening nutrition habits, physical inactivity and increasing obesity levels have led to increased fractures in children over recent years.

Because 90% of bone mass is accumulated before adulthood, bone fragility during childhood and adolescence can have long-term implications. Identifying children with primary and secondary osteoporosis can minimize further bone loss and fractures later in life.

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