Can We Prevent Children’s Fractures?

Published on 11/03/2015 by admin

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Chapter 24 Can We Prevent Children’s Fractures?

ANDREW. HOWARD, MD, MSc, FRCSC

Injury is currently one of the leading causes of burden of disease, accounting for 9% of worldwide morbidity and mortality combined in 1998. Injury is expected to account for a much greater share—14% of global morbidity and mortality by 2020.1,2 The expected increase is attributable both to increased motorization leading to a greater burden of road traffic crashes, and to the demographic and epidemiologic transition whereby diseases of poverty (malnutrition, infections) become replaced by those of affluence (trauma, diabetes, heart disease, cancer) as global wealth increases and population growth rates slow.3

Many fields of medicine (e.g., cardiology) consider the scientific understanding of prevention of disease as implicit in clinical practice. The prevention of fractures, both at the individual and at the population level, is an important aim toward which orthopedic surgeons have much to contribute. Injury prevention is in itself a broad scientific field as exemplified by the scope and depth of articles presented in a leading journal,Injury Prevention. Fractures are a common feature of many injury events from the high- (e.g., road traffic) to the low-energy (sports, falls) mechanisms. It is not the purpose of this chapter to review the general evidence supporting the statement that most injury events among children are, in fact, preventable. Rather, this chapter focuses on clinical aspects of the prevention of fractures in the population pediatric orthopedists treat as patients specifically. The relationship between bone health and fractures among healthy children and among children with medical comorbidities is considered. Evidence about the prevention of refractures in clinical practice is examined.

BONE HEALTH AND FRACTURES AMONG HEALTHY CHILDREN

Increasing longevity puts more of the population at risk for osteoporotic fractures in old age. Ensuring attainment of the greatest possible peak bone mass in childhood and adolescence is an obvious but difficult to implement step at a societal level. Attainment and maintenance of bone mass relies on adequate dietary calcium, availability of vitamin D, weightbearing exercise, and hormonal milieu. Peak bone mass is attained by early adulthood and declines thereafter; therefore improving bone health for a lifetime requires interventions in childhood and adolescence.4 Whether these same interventions will reduce childhood or adolescent fractures is unclear. A transient osteoporosis of adolescence coinciding with peak height growth velocity has been hypothesized, and it may increase fracture incidence at this time.

Randomized, controlled trial (level I) evidence demonstrates that oral calcium supplementation increases the bone mineral density (BMD) of female children during the pubertal growth spurt; however, at 7 years of follow-up, there was no difference in total body BMD and distal radius BMD.5 A randomized, controlled trial combining exercise intervention and calcium supplementation in 16- and 18-year-old girls found a significant increase in BMD (at 1 year) with calcium supplementation, but no additional effect from a weightbearing exercise program prescribed to individuals.6 A prospective, nonrandomized study from Sweden (level II evidence) used a school-based exercise program and showed that classes of girls given daily physical exercises had improved BMD and bone width compared with classes doing physical exercise once per week.7

An increased risk for forearm fractures from reduced BMD has been established prospectively for girls using a cohort design (level II evidence)8 and retrospectively for boys using a case–control design (level III evidence).9 In both of these studies, an increased body mass index was also found to be an independent predictor of increased fracture risk.

In summary, among healthy children, it is possible to increase the BMD over the short term by adding calcium to the diet and perhaps by implementing group exercise programs. Children with lower BMD are at increased risk for forearm fractures. Intervention trials with fracture outcomes (rather than bone density outcomes) have not yet been done among children.

BONE HEALTH AND FRACTURES AMONG CHILDREN WITH COMORBIDITIES

Osteogenesis Imperfecta

Osteogenesis imperfecta is a group of related conditions in which defects in collagen production lead to bony fragility and fractures. Bone turnover is high, particularly during the growing years. Bisphosphonates decrease osteoclastic resorption of bone, leading to increased bone mass and bone strength. Two randomized, controlled trials (level I evidence) support treating patients with osteogenesis imperfecta with oral bisphosphonates. One trial randomized 34 children to either oral olpadronate (10 mg/m2 daily) or placebo, in addition to calcium and vitamin D for all patients. A 2-year parallel arm design was used. Olpadronate-treated patients had a 31% reduction in long-bone fracture risk. Increases in BMD and bone mineral content were statistically significantly greater among olpadronate-treated patients. No difference was found in overall quality of life.10 A second trial randomized 17 children to oral alendronate or placebo in a blinded crossover study and showed increases in BMD, increases in quality of life in the domains of pain, analgesic use, and well-being, as well as decreases in the number of fractures during the time of alendronate treatment.11

Earlier studies regarding bisphosphonates for Osteogenesis imperfecta were case series (level IV evidence) that documented increased bone mineral densities, decreased serum markers of bone turnover, and decreased numbers of fractures after treatment with intravenous pamidronate.12–15

Cerebral Palsy/Neuromuscular Conditions

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