Repeat Fractures May Indicate Osteoporosis in Children

November 03, 2003

Alicia Ault

Nov. 1, 2003 (New Orleans) — Children who experience repeated fractures may have osteoporosis and probably should receive dual-energy x-ray absorptiometry (DEXA) bone mineral density screening, researchers reported here Saturday at the American Academy of Pediatrics National Conference and Exhibition.

Michael Wildstein, MD, an orthopedic resident at the Medical University of South Carolina in Charleston, reported data from a collaborative study by Frederick Reed, MD, FAAP, and Lyndon Key, MD, both colleagues at the University. Dr. Reed was the moderator of the session and thus did not present the paper himself.

The physicians decided to conduct the study after noticing that some children presented repeatedly for fracture. "We were interested in the prevalence of osteoporosis in children," Dr. Wildstein told attendees.

Because 90% of bone mass is formed by age 12 to 19 years, "the more bone mass you accumulate up to adolescence, the more protection you have later in life," said Dr. Wildstein. If the researchers could pinpoint children at risk through DEXA bone scans, they could recommend interventions to build bone.

A total of 447 children aged 6 to 13 years who presented with fractures due to minimal trauma were evaluated. Sixty-seven had two or more fractures, and 14 had three fractures, reported Dr. Wildstein. The fractures were not due to underlying disorders or steroid use, Dr. Wildstein said.

Sixteen of these children were sent to Dr. Key for DEXA scans of the spine and hip.

Dr. Key is studying whether the bisphosphonate alendronate can be safely and effectively used in children with osteoporosis. His work is funded by a National Institutes of Health (NIH) grant, Dr. Wildstein told Medscape.

Based on Dr. Key's scans of the 16 children, 67% were found to be osteoporotic. Dr. Reed and Dr. Wildstein estimated that the rate of second fracture in an average orthopaedic practice would be 15%.

Some audience members questioned whether the DEXA measurements were valid, or if they were just a snapshot of a child's growth progression. Dr. Wildstein told attendees that he and his colleagues used normative data from a multicenter trial conducted by Dr. Key, but he acknowledged that there are no solid norms for bone mineral density in children.

The NIH is conducting a multicenter study to set those parameters, which should be reported in a month or so, commented Dr. Reed.

He is recommending DEXA bone scans for children aged 6 to 13 years who have two or more fractures due to minimal trauma. Children should also be referred to a pediatric endocrinologist if bone mineral density is two standard deviations below the norm. Physicians should actively counsel parents and patients on the risk factors for osteoporosis, which include physical inactivity.

The study should raise red flags for orthopaedists, Dr. Wildstein told Medscape in an interview. "We're trying to increase awareness...that there's something that requires an intervention here," he said. "It is not normal for children to break bones so easily."

Richard Justis Haynes, MD, FAAP, chief of staff at Shriner's Hospital in Houston, Texas, agreed with Dr. Wildstein that the data should get orthopaedists' attention. "In the past, we've always assumed that a high rate of fractures is just due to them being active kids," Dr. Haynes told Medscape.

The Reed study "was a very well done review that provides some fairly strong evidence that osteoporosis most likely is an issue with repeated fractures," he said.

AAP 2003 National Conference and Exhibition. Presented Nov. 1, 2003.

Reviewed by Gary D. Vogin, MD

Alicia Ault is a freelance writer for Medscape.