From the Guidelines
The approach to recurrent fractures in children should prioritize optimization of age-appropriate dietary and supplemental calcium and vitamin D, as well as an exercise program, with consideration of oral or IV bisphosphonate therapy for those on chronic glucocorticoids at a dose of ≥0.1 mg/kg/day for >3 months. When evaluating a child with recurrent fractures, it is essential to obtain a detailed history, including previous fractures, mechanism of injury, dietary habits, physical activity levels, and family history of bone disorders 1. A thorough physical examination should be performed to identify signs of underlying conditions, and laboratory testing should include calcium, phosphorus, alkaline phosphatase, vitamin D levels, parathyroid hormone, and complete blood count. Radiographic evaluation, including plain films of the fracture site and a skeletal survey if indicated, can help identify occult fractures. Bone mineral density testing via dual-energy X-ray absorptiometry (DXA) is recommended for children with recurrent fractures, adjusting for age, sex, and height. Key considerations in the management of recurrent fractures in children include:
- Optimizing vitamin D levels and ensuring adequate calcium intake
- Addressing any identified metabolic bone disorders
- Considering bisphosphonate therapy for children with osteogenesis imperfecta or those on chronic glucocorticoids
- Implementing physical therapy to improve muscle strength and coordination
- Regular follow-up to monitor bone health and treatment response. It is crucial to consider child abuse in cases of recurrent fractures with inconsistent histories, especially in non-ambulatory children or those with fractures at different healing stages 1.
From the Research
Approach to Recurrent Fracture in Children
- Recurrent fractures in children can be caused by various factors, including osteoporosis, genetic bone disorders, and secondary medical conditions 2
- A detailed medical history, physical examination, and laboratory investigations are essential to determine the underlying cause of recurrent fractures in children 2, 3
- Bone mineral density assessment and vertebral radiographs can help identify children with osteoporosis 2, 4
Evaluation and Diagnosis
- Dual-energy X-ray absorptiometry (DXA) is a useful tool for assessing bone mineral density in children, but interpretation of results can be challenging due to dynamic variables such as age, sex, and ethnicity 5, 3
- Z-scores, which compare bone mineral density to age-, sex-, and ethnicity-matched controls, can help identify children with low bone mineral density 3, 4
- A comprehensive bone and systemic health assessment is necessary to eliminate underlying pathology in children with recurrent fractures 4
Risk Factors and Prevention
- Modifiable risk factors such as low milk intake, lack of exercise, and high consumption of carbonated beverages can increase the risk of recurrent fractures in children 5
- Conservative measures such as calcium and vitamin D supplementation, weight-bearing physical activity, and optimization of underlying medical conditions can help prevent recurrent fractures 2, 3
- Bisphosphonates may be used in children with significantly compromised quality of life, but their use is controversial due to lack of long-term efficacy and safety data 3
Screening and Assessment
- A screening evaluation for children with a history of frequent fractures should include a dietary history, physical examination, and urinary calcium concentration/creatinine ratio determination 6
- Children with abnormalities in this screening should undergo dual-energy radiographic absorptiometry and appropriate evaluation to identify underlying bone disease or other conditions 6