Bone Health Evaluation in the Child Vulnerable to Fracture


Bone Health Evaluation in the Child Vulnerable to Fracture


During childhood, bones go through a unique process of remodeling that is different from any other phase of growth.

Remodeling is regulated by local cytokines; by circulating hormones, including parathyroid hormone (PTH), 1,25-dihydroxyvitamin D (1,25-OH2-D), insulin-like growth factor 1 (IGF-1); and by calcitonin

During adolescence, osteoblasts (involved in bone formation) are more active than osteoclasts (involved in bone resorption), leading to net accrual of bone mass.

Normal development leads to a 90% increase in bone growth over the first 2 decades after birth and to almost half of adult bone mass accrual in adolescence.

Peak bone mineralization occurs approximately 1 to 1½ years after the peak in height velocity (Figure 43-1).

Optimal bone health is achieved with proper nutrition, muscle mass development, and load-bearing activities. A number of variables can interfere with the bone remodeling and growth process during childhood (Figure 43-2).

When to Consider Bone Health Workup

Criteria for when to initiate a bone health workup or refer to a bone health specialist are controversial. Box 43-1 lists some considerations.

Conditions that affect bone health

Genetic disorders

Connective tissue disorders, such as Marfan syndrome, Loeys-Dietz syndrome, and Ehlers-Danlos syndrome

Fibrous dysplasia

Gaucher disease


Glycogen storage diseases



Figure 43-1. A graph of bone mineral accrual in boys and girls. BMC, bone mineral content; PHV, peak height velocity; TB, total bone.

Reproduced from Bailey DA, McKay HA, Mirwald RL, Crocker PRE, Faulkner RA. A six-year longitudinal study of the relationship of physical activity to bone mineral accrual in growing children: The University of Saskatchewan Bone Mineral Accrual Study. J Bone Miner Res. 1999;14(10):1672–1679.


Figure 43-2. Bone health over time. Abbreviation: Vit D, vitamin D.

Reprinted from Heaney RP, Abrams S, Dawson-Hughes B, et al. Peak bone mass. Osteoporos Int. 2000;11(12):985–1009. © 2000, with permission from Springer Nature.

Box 43-1. When to Consider Referral to a Bone Health Specialist or Initiating a Bone Health Workupa

Atypical fractures (hip, femoral, or vertebral)

Fractures that occur with minimal trauma or low velocity

History of multiple fractures (>2)

a Workup includes dual-energy x-ray absorptiometry scan and laboratory studies.

Menkes disease (ie, kinky hair syndrome)

Osteogenesis imperfecta

Turner syndrome

Idiopathic juvenile osteoporosis

Chronic disease and nutritional deficits

Anorexia, dysphagia, and failure to thrive are examples of conditions that affect nutritional intake of calcium, magnesium, phosphorus, and vitamin D

Dairy avoidance due to milk allergy or lactose intolerance may also affect nutritional intake

Conditions causing intestinal inflammation can limit absorption of minerals (eg, celiac disease, inflammatory bowel disease, colitis, cystic fibrosis)

Autoimmune and endocrine disorders

Juvenile idiopathic arthritis, systemic lupus erythematosus, and multiple sclerosis

Hyperthyroidism, specifically, Graves disease

Glucocorticoid excess (endogenous or iatrogenic)

Growth hormone deficiency

Sex steroid deficiency or resistance

Type 1 diabetes


Relative energy deficiency in sport (RED-S) (see Chapter 33, Overuse Injuries)

Previously called female athlete triad, RED-S includes male athletes.

Athlete with disordered eating and suppressed gonadotropic hormones. This is exhibited in females as amenorrhea or oligomenorrhea and decreased bone density.

Neuromuscular conditions

Cerebral palsy, muscular dystrophies and spinal muscular atrophy, and paraplegia

Risks increase with the severity of disease.

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Mar 12, 2022 | Posted by in ORTHOPEDIC | Comments Off on Bone Health Evaluation in the Child Vulnerable to Fracture

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