Childhood Fracture Linked to Increased Risk of Subsequent Fracture

By Will Boggs MD

July 17, 2019

NEW YORK (Reuters Health) - Childhood fracture is associated with an increased risk of fracture later in childhood or early adulthood, according to a retrospective population-based study in Ontario, Canada.

"I find it interesting that one fracture predicts future fractures in children, when we controlled for other injury types," Dr. Andrew W. Howard from The Hospital for Sick Children, Toronto, Ontario, Canada told Reuters Health in an email interview. "This suggests to me that the reason for multiple fractures may be weaker bone, rather than riskier environment or riskier behavior. We know that one fracture predicts another in older adults with weak bone, and now we may be finding out that the same applies to children."

About half of boys and one-third of girls experience fractures during childhood, and the incidence of childhood fractures after low-energy falls appears to be rising, raising concerns about suboptimal bone health in childhood resulting from declining activity levels, worsening nutrition, or rising rates of childhood obesity.

Dr. Howard's team used information from linked Ontario health administrative databases to determine whether children who sustained a fracture in childhood have an increased rate of fracture later in childhood or early adulthood.

During the one-year baseline period, 1.75% of approximately 2.5 million Ontario children experienced a fracture.

During the seven-year follow-up period, 23.0% of children with a baseline fracture experienced at least one fracture, compared with only 11.3% of children with no baseline fracture.

Differences were evident for single fractures during follow-up (18.3% versus 9.9%, respectively), two fractures (3.8% versus 1.3%, respectively), and three or more fractures (0.9% versus 0.2%, respectively), according to the July 15th Pediatrics online report.

After adjustment for sex, rurality, history of previous fracture, and the occurrence of other injuries, children with a baseline fracture had a 60% higher rate of fracture during follow-up, compared with children without a baseline fracture.

The increased relative risk of subsequent fracture was higher for fractures in early childhood (about 70% increased risk for 0-5 years of age) than for fractures later in childhood (about 50% increased risk for 6-15 years of age).

"A single fracture is so common in childhood that I do not believe any clinical testing is typically warranted," Dr. Howard said. "However, the opportunity for secondary prevention can be taken by ensuring the child and parents know how weightbearing exercise, diet, and vitamin D contribute to optimizing bone strength during growth."

"After multiple fractures, a clinical assessment of bone health may be indicated," he said. "For children with a strong family history of childhood fracture or with other phenotypic features of bone disease (blue sclerae, lax joints), an earlier assessment may be warranted."

Dr. Howard added, "When clinicians are thinking about the meaning of a fracture, I do not want them to forget to assess for the possibility of inflicted injury. While that has nothing to do with the results in this paper, it is important in clinical care."

Dr. Laura K. Bachrach from School of Medicine, Stanford University, Stanford, California, who wrote an editorial related to this report, told Reuters Health by email, "As with so many conditions facing the primary care provider, the challenge is knowing when to worry about a common injury and how far to go in evaluating. This is analogous to the decisions made when children present with a fever - what work up is needed. I'd hope the provider would be a good clinical detective, order more tests if suspicious and always make a pitch for the importance of optimizing gains in bone strength while the skeleton is young and responsive."

"I'd hope physicians would take note of fractures, explore the clinical history in detail as described (that is not a time-consuming or costly 'ask'), and explore in more detail those fractures that seem atypical (low trauma, femur, vertebral, etc.)," she said. "I'd also hope that physicians would use this injury as an opportune time to champion the importance of taking bone health seriously. Too many youth are not consuming enough calcium, being physically active, maintaining a healthy weight, etc."

"What I would caution against is doing a bone density test (DXA scan) unless suspicion of abnormal bone pathology is high," Dr. Bachrach said. "The results can be misinterpreted unless delivered by those experienced in pediatric densitometry and a 'normal' bone mineral density (Z score better than -2) does not preclude abnormal bone quality."


Pediatrics 2019.