Approach to the child with fractures

Abstract

Evaluation of the child with fractures is challenging, as no clear guidelines exist to distinguish traumatic from pathological fractures. Although most fractures in childhood are benign, recurrent fractures may be associated with a wide variety of primary skeletal diseases as well as secondary causes, necessitating a careful history and physical exam to guide the evaluation. There is no "gold standard" for the evaluation and treatment of children with fractures and low bone mineral density (BMD); therefore, the diagnosis of osteoporosis in a pediatric patient should be made using a combination of clinical and radiographic features. Interpretation of bone densitometry in growing patients presents a unique set of challenges because areal BMD measured by dual-energy x-ray absorptiometry depends on multiple dynamic variables. Interpretation of pediatric dual-energy x-ray absorptiometry should be based on Z-scores (sd scores compared to age, sex, and ethnicity-matched controls), using normative databases specific to the brand of densitometer and the patient population. Given the skeleton's ability to recover from low BMD through modeling and remodeling, optimizing management of underlying conditions leading to bone fragility is the initial step. Conservative measures including calcium and vitamin D supplementation and weight-bearing physical activity are important interventions that should not be overlooked. The use of bisphosphonates in children and adolescents is controversial due to lack of long-term efficacy and safety data and should be limited to clinical trials and compassionate therapy in children with significantly compromised quality of life. Close monitoring is required, and further study is necessary to assess their long-term safety and efficacy in children.

Fig. 1.

Growth chart of girl with osteoporosis. Decline in height percentile with absolute height loss is apparent after the development of multiple thoracic compression fractures between ages 10 and 12 yr. Pamidronate was initiated at age 12, associated with recovery of height and continued linear growth.

Fig. 2.

BMD Z-score and T-score for a 12-yr-old child (23). The curves demarcate the normal (mean ± 2 sd) areal BMD of the lumbar spine, which depends on skeletal size and thus increases with age. The square symbol represents a patient who received an erroneous diagnosis of osteoporosis based on a low T-score. The Z-score of this patient is well within the normal range for age.

Fig. 3.

Hyperdense sclerotic bands in the epiphyses of a child treated with serial infusions of pamidronate. [Reproduced with permission from M. Al Muderis et al.: J Bone Joint Surg Am 89:1511–1516, 2007 (76).]