Symptomatic fracture incidence in those under 50 years of age in southern Tasmania

Multicenter epidemiological analysis of related factors in 10,808 hospitalized children with lower limb and pelvic fractures in China

To analyze the causes, locations, associated injuries, and relevant factors of lower limb and pelvic fractures in hospitalized children in China to provide a theoretical basis for reducing the incidence of such fractures. A retrospective analysis of children with lower limb and pelvic fractures admitted to 27 tertiary children's hospitals affiliated with China's Futang Research Center of Pediatric Development between December 1, 2015, and December 31, 2019, was conducted. Inpatient cases were analyzed in the following age groups: Infants (< 2 years), Preschool children (2-5 years), School children (6-11 years), and Adolescents (12-18 years). This study included 10,808 pediatric patients (7152 males, 3656 females). The proportion of preschool children of lower limb and pelvic fractures was the highest. The 10,808 patients sustained a total of 14,398 fractures. The shafts of the femur, tibia, and fibula, the distal tibia, distal fibula, and the pelvis were the six most common locations. Of the 734 pelvic fractures in children and adolescents, the top three locations were the ilium, pubic bone, and the ischium. Of the total patients, 9599 underwent surgery, while 1209 received non-surgical treatment. The three most common causes of pediatric lower limb and pelvic fractures were falling over, traffic accidents, and falling from a height. Among the 1806 concomitant traumas, respiratory traumas was the most common, mainly pulmonary contusion. The most common concomitant traumas of nervous, digestive and urinary system were scalp hematoma, liver injury and kidney injury respectively. The analysis of the location, age, causes, and concomitant injuries of lower limb and pelvic fractures showed that the most common fracture requiring hospitalization was tibia fracture, which was most common in preschool children. The most common cause of injury in preschool children was traffic accident. In addition, children are susceptible to accidental injuries from multiple sources in life, which can cause serious consequences of multi-system injuries.

The comparative performance of radial head prostheses in patients younger than and older than 50 years: a systematic review

Background

Patient age may play a role in the surgeon's decision between radial head arthroplasty (RHA) and open reduction internal fixation in radial head fracture treatment. Though large sample reports have detailed outcomes of radial head replacement for a mean age younger than 50 years, the age ranges are widely distributed. Patient outcomes are not uniform across a broad age distribution. Therefore, treatment decisions should be evaluated within the confines of a narrower age bracket. An understanding of clinical outcomes for radial head replacement in younger adults will provide value for guiding treatment decisions. We performed a systematic review comparing the clinical outcomes for radial head replacement in patients younger and older than 50 years of age. Further analysis compared outcomes between RHA performed as a primary procedure and as a secondary procedure in patients younger and older than 50 years of age.

Methods

PubMed was queried for articles which delineated individual patient data for age, surgical treatment, and appropriate outcome metrics. Articles were grouped based on patient age of under 50 and over 50 years and within those age groups, based on the arthroplasty being performed as a primary or as a secondary procedure.

Results

There were no significant differences between the under 50 and the over 50 groups for Mayo Elbow Performance Score (P = .79) and for implant revision/removal (P = .32). In the under 50 group, RHA done as a primary procedure had significantly higher (P = .001) mean Mayo Elbow Performance Score than RHA done as a secondary procedure. In the over 50 group, relative risk was 2.39 (95% confidence interval, 2.12-2.69) for implant revision/removal (P = .11) when comparing primary and secondary procedures.

Discussion

At a mean follow-up of 48 months, RHA in patients under the age of 50 years had satisfactory outcomes which were comparable to outcomes in patients over the age of 50 years. Across both age groups, arthroplasty performed as a primary procedure demonstrated superior outcomes compared to arthroplasty performed as a secondary procedure. Our findings provide guidance to surgeons who face a multifaceted decision when encountering younger adult patients with radial head fracture patterns that may not be amenable to fixation. Awareness of the age-specific performance of radial head implants is an important component of the decision for surgical treatment.

Fracture incidence in children and adolescents 0-19 years old in Mexico: a 12-year cross-sectional analysis

The objective was to know the behavior of fractures in Mexican children and adolescents. According to our study, fractures in Mexican male children and adolescents seem to be decreasing; however, we still need more national studies to know the possible causes of these fractures.

PURPOSE

To describe the trends of fractures in Mexican children and adolescents across a 12-year period (2007 to 2019), and to analyze if these trends have changed over time between sexes and age groups.

METHODS

We identified all fracture cases registered in children and adolescents (0 to 19 years) at the emergency rooms and surgical departments of the Mexican Institute of Social Security between January 2007 and December 2019. We used ICD-10 to classify the fractures. The population was divided into two age groups: children (0 to 9 years) and adolescents (10 to 19 years). Additional information regarding sex and age was gathered up as well. We calculated annual incidence; incidence rates are presented per 10,000 population at risk. Changes in fracture trends were calculated using the average annual percentage change (AAPC).

RESULTS

Over 12 years, 1,400,443 fractures were registered. The most frequent site of fracture was forearm in 37.1% followed by shoulder (18.1%). The overall rates of fractures have remained similar over 12 years (86.5, IQR 81.0-94.2); however, a significant decrease in fractures was observed the last 3 years (2017-2019). According to the AAPC, only in men, in both age groups, a significant decrease in fractures was observed.

CONCLUSION

This is the first study in Mexico to follow the behavior of fractures in the pediatric population over 12 years. Fractures seem to be decreasing in children and adolescents. An epidemiological follow-up of childhood fractures is necessary to understand the causes of fractures to generate better prevention and treatment strategies.

Incidence, characteristics, and treatments of traumatic open fractures in children and adolescents: A retrospective observational study

We aimed to investigate the incidence, characteristics, and treatments of open fractures in children and adolescents (≤18 years old). We retrospectively reviewed the records of 2418 children and adolescents who presented with traumatic fractures and were admitted to our university-affiliated hospitals, among which 206 patients (8.5%) presented with open fractures. The patients' clinical and radiographic records were reviewed, and the age, gender, cause of injury, injury season, injury week, associated injuries and complications were collected. This study enrolled 1789 males (74.0%) and 629 females (26.0%) with an average age of 11.2 ± 5.0 years. The patients were divided into an open fracture group (OF group, n = 206) and a group with no open fracture (No-OF group, n = 2212). There were 206 patients (8.5%) who presented with open fractures and the most common fracture sites were the tibia (31.1%, 64/206) and fibula (20.9%, 43/206). The patients in the OF group presented with higher frequency of emergency admission (P < 0.001), self-supporting medical insurance (P < 0.001), MVCs (P < 0.001), wounded by machine (P < 0.001), struck by object (P < 0.001), hurt/cut by others (P < 0.001), lower limb fractures (P < 0.001), multiple fractures (P = 0.010), associated injuries (P < 0.001) and wound infection (P = 0.003) then the patients in the No-OF group. The most common complication were wound infection (5.8%) and pneumonia (1.0%) in the OF group, wound infection (2.1%) and pressure sores (2.0%) in the No- OF group. Multivariate logistic regression analysis indicated that mechanical trauma (OR = 64.229, P < 0.001), being hurt/cut by others (OR = 26.757, P < 0.001), and being struck by an object (OR = 15.345, P < 0.001) were stronger risk factors for open fracture than were low falls; additionally, lower limb fractures (OR = 5.970, P < 0.001), upper limb fractures (OR = 5.865, P < 0.001) and multiple fractures (OR = 5.414, P < 0.001) were stronger risk factors than craniofacial fractures for open fractures. The frequency of surgical treatment for the patients with traumatic open fractures (87.9%, 181/206) was significantly higher than those without open fractures (72.2%, 1596/2212) (P < 0.001). The hospital stays and fees for surgical treatment for the patients with traumatic open fractures were significantly higher than those without open fractures (P < 0.001). Etiology (especially being injured by a machine or being hurt/cut by others) and the fracture site (including lower limb fractures and upper limb fractures) were independent risk factors for open fractures. Traumatic open fractures presented with higher surgical treatment rate, hospital stays and fees.

Upper limb pediatric fractures in 22 tertiary children's hospitals, China: a multicenter epidemiological investigation and economic factor analysis of 32,832 hospitalized children

BACKGROUND

Fractures are the most common type of unintentional injury in children, with traumatic upper limb fractures accounting for approximately 80% of all childhood fractures. Many epidemiological investigations of upper limb fractures in children have been conducted, but with the development of society, the patterns of childhood fractures may have changed. This study aimed to analyze the epidemiology and economic cost factors of upper limb fractures in Chinese children.

METHODS

We retrospectively reviewed children with upper limb fractures or old upper limb fractures hospitalized between December 1, 2015, and December 31, 2019, in 22 tertiary children's hospitals, under China's Futang Research Center of Pediatric Development. We used the ICD10 codes on the front sheet of their medical records to identify cases and extracted data on age, sex, injury cause, fracture site, treatment, the year of admission and discharge, visiting time, and various costs during hospitalization from the medical record.

RESULTS

A total of 32,439 children (21,478 boys and 10,961 girls) were identified, of whom 32,080 had fresh fractures and 359 had old fractures. The peak age was 3-6 years in both sexes. A total of 4788 were infants, 14,320 were preschoolers, 10,499 were in of primary school age, and 2832 were adolescent. Fractures were most frequent in autumn (August to October). Admissions peaked at 0 o'clock. Among the 32,080 children with fresh upper limb fractures, the most common fracture site was the distal humerus, with a total of 20,090 fracture events including 13,134 humeral supracondylar fractures and 4914 lateral humeral condyle fractures. The most common cause of injuries was falling over. The most common joint dislocation accompanying upper limb fractures occurred in the elbow, involving 254 cases. Surgery was performed in 31,274 children, and 806 did not receive surgery. Among those with clear operative records, 10,962 children were treated with open reduction and 18,066 with closed reduction. The number of cases was largest in the East China region (Anhui Province, Shandong Province, Jiangsu Province, Zhejiang Province, and Fujian Province), with 12,065 cases overall. Among the 359 children with old fractures, 118 were admitted with a diagnosis of "old humerus fracture," accounting for the highest proportion; 244 underwent surgical open reduction, 16.16% of whom had osteotomy. For the children with fresh fractures, the average total hospital cost was 10,994 yuan, and the highest average total hospital cost was 14,053 yuan, for humeral shaft fractures. For the children with old fractures, the average total hospital cost was 15,151 yuan, and the highest average total hospital cost was 20,698 yuan, for old ulna fractures. Cost of materials was the principle factor affecting total hospital cost, followed by surgery and anesthesia costs, both in children with fresh fractures and those with old fractures. Significant differences were observed in all hospital costs (P < 0.001) except treatment costs (P = 0.702), between children with fresh fractures and those with old fractures. Among the 32,439 children, full self-payment accounted for the highest proportion of all payment methods, involving 17,088 cases, with an average cost of 11,111 yuan.

CONCLUSION

Information on the epidemiological characteristics of childhood fractures suggests that health and safety education and protective measures should be strengthened to prevent upper limb fractures in children. For both fresh and old fractures, the cost of materials was the principal factor affecting total hospital cost, followed by surgery and anesthesia costs. The overall average total hospital cost is higher in children with old fractures than in children with fresh fractures. Among all children, full self-payment, at 53% of children, accounted for the highest proportion of all payment methods. Hospital costs are a headache for those families who will pay on their own. It can lead to a delayed treatment and unhealed fractures or malunion in some children. Therefore, the child trauma care system and training on fractures need to be improved, to reduce the late presentation of fractures. These combined measures will improve children's quality of life, reduce the expenditure of families, and decrease the public health burden. To provide better medical services for children, authorities must improve the allocation of health resources, establish a comprehensive medical security system for children, and set up more child trauma centers.

Epidemiology and management of 10,486 pediatric fractures in Shenzhen: experience and lessons to be learnt

Purpose

To explore and analyze the causes and related influencing factors of pediatric fractures, and provide theoretical basis for reducing the incidence and adverse effects of pediatric fractures.

Methods

This study retrospectively analyzed the epidemiological characteristics of fractures in pediatric aged ≤18 years old who were admitted to the our hospital between July 2015 and February 2020.

Results

A total of 10,486 pediatric patients were included in the study, of whom 6961 (66.38%) were boys, and 3525 (33.62%) were girls. For the fracture incidence, age group of the 3-6 years reached the peak. 5584 (60.76%) children were operated upon within 12 h after admission. The top three types of fractures were the distal humerus (3843 sites, 27.49%), distal ulna (1740 sites, 12.44%), and distal radius (1587 sites, 11.35%). The top three causes of injury were falls (7106 cases, 82.10%), car accidents (650 cases, 65.72%), and clipping (465 cases, 5.37%). Fractures predominantly occurred between July and November (4664 cases, 48.87%) and on Saturdays and Sundays (3172 cases, 33.24%). The highest number of hospital visits occurred between 20:00 and 00:00 (4339 cases, 45.46%).

Conclusion

For pediatric fractures, we should take appropriate and effective preventive measures to reduce the incidence of children’s fractures according to the distribution characteristics of age, gender, cause of injury, and fracture site.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03199-0.

Upper Extremity Fractures in Children-Comparison between Worldwide, Romanian and Western Romanian Region Incidence

(1) Background: Fractures represent a significant part of all pediatric injuries, with distal forearm fracture being the most common fracture type in children. (2) Methods: In this comparative, epidemiological study we collected fracture incidence data from the scientific literature and compared it to real-world data extracted from the Romanian national and regional hospital database. In order to collect information on the epidemiology of upper extremity fractures in children, we conducted a systematic literature review on Medline, via PubMed. Extracted incidence data were stratified by fracture location, age or age interval and gender. Nationwide and Western Region incidence values were calculated for different fracture locations of the upper extremity using data extracted from a centralized hospital database. Incidence values were calculated using the mid-2018 census data. The search was restricted to the pediatric population. (3) Results: Incidence values for upper arm fractures nationwide and for Western Region were 54.83/100,000 person-years and 64.79/100,000 person-years, respectively. Forearm fractures had an incidence of 139.77/100,000 person-years and 139.56/100,000 person-years, respectively. The overall incidence of upper extremity fractures nationwide and for the Romanian Western Region were 206.02/100,000 person-years and 220.14/100,000 person-years, respectively. (4) Conclusions: Incidence of upper extremity fractures in the pediatric population varies according to the analyzed data. The calculated incidence depends on the site of fractures, assessed population (worldwide, Romanian population or regional-Western part of Romania) or patients' age.

Distal radius bone microarchitecture: what are the differences between age 25 and old age?

This study reported that the transitional zones in older adults were enlarged at the expense of the compact-appearing cortex with a greater porosity in all cortical sub-compartments. The magnitude of differences in areal and volumetric bone mineral density (aBMD, vBMD) between older and younger groups was similar.

INTRODUCTION

Aging is strongly associated with bone loss, but little is known about magnitudes of differences in bone microarchitectures, aBMD, and vBMD from peak bone mass (PBM) to senescence. We aimed to describe differences in aBMD, vBMD, and bone microarchitecture parameters at the distal radius between older and young adults.

METHODS

We compared 201 participants, aged 62-89 years (female 47%) and 196 participants, aged 24-28 years (female 38%). Bone microarchitecture parameters at distal radius were measured using high-resolution peripheral computed tomography (HRpQCT). aBMD was measured using dual-energy X-ray absorptiometry (DXA). Unpaired t tests and chi-square tests were used to compare differences in means and proportions as appropriate.

RESULTS

Older adults had thinner compact-appearing cortices with larger (cross-sectional area: outer 30.96 mm² vs. 28.38 mm², inner 36.34 mm² vs. 32.93 mm²) and thicker (outer 0.57 mm vs. 0.54 mm, inner 0.71 mm vs. 0.65 mm) transitional zones compared with young adults (all p < 0.05). Cortical porosity was modestly higher in older adults than in young adults (54% vs. 49%, p < 0.001). The magnitude of the difference in hip aBMD between older and young adults was slightly lower than of total radial vBMD (- 0.51 SD vs. - 0.78 SD).

CONCLUSION

Compared with young adults at the time of PBM, the transitional zones in older adults were enlarged at the expense of the compact-appearing cortex with a greater porosity in all cortical sub-compartments. The similar SD differences in aBMD and vBMD between older and younger groups suggest that the differences in bone area are not leading to major artefactual change in aBMD.

The Association between First Fractures Sustained during Childhood and Adulthood and Bone Measures in Young Adulthood

OBJECTIVE

To describe the association between fractures sustained at different stages of growth and bone measures in early adulthood.

STUDY DESIGN

Participants (n = 201) in southern Tasmania were at birth at a higher risk of sudden infant death syndrome; they were followed to age 25. Outcomes were areal bone mineral density at the spine, hip, and total body (by dual-energy x-ray absorptiometry) and trabecular and cortical bone measures at the radius and tibia (by high-resolution peripheral quantitative computed tomography). Fractures were self-reported and confirmed by radiographs at 8, 16, and 25 years of age. Multivariable linear regression was used to analyze the association of the occurrence of prepubertal (<9 years of age), pubertal (9-16 years of age), and postpubertal (17-25 years of age) fractures with all bone measures.

RESULTS

Over 25 years, 99 participants had at least 1 fracture. For high-resolution peripheral quantitative computed tomography measures at age 25, prepubertal fractures were negatively associated with cortical and trabecular volumetric bone mineral density and most microarchitecture measures at both the tibia and radius. Prepubertal fractures had a significant association with smaller increase of areal bone mineral density from age 8 to 16 years and at 25 years of age compared with participants with no fractures. Pubertal fractures had no association with any bone measures and postpubertal fractures were only associated with a lower trabecular number at the tibia.

CONCLUSIONS

Prepubertal fractures are negatively associated with areal bone mineral density increases during growth and high-resolution peripheral quantitative computed tomography bone measures in young adulthood. There is little evidence that fractures occurring from age 8 years onward with bone measures in young adulthood, implying that prepubertal fractures may be associated with bone deficits later in life.

Incidence patterns of traumatic upper limb fractures in children and adolescents: Data from medical university-affiliated hospitals in Chongqing, China

China's child population ranked second in the world. However, data on the overall patterns and epidemiologic trends of TULFs among children and adolescents in Chongqing, China are scarce. With development of urbanization, motorization, building industry, the incidence patterns of traumatic upper limb fractures in children and adolescents might be about to change. To investigate the incidence patterns of traumatic upper limb fractures in children and adolescents (≤18 years old) according to age (≤3 years old, 3-6 years old, 6-12 years old, and 12-18 years old), gender, time, and etiology groups in Chongqing, China, we retrospectively reviewed 1078 children and adolescents who had traumatic upper limb fractures and who came to our university-affiliated hospitals from 2001 to 2010. The patients were grouped into different age groups, genders, year of admission range groups, and aetiologies. We used Pearson chi-square tests and independent samples t tests to assess differences of the grouped data and continuous variables, respectively. This study enrolled 1078 patients (849 males, 229 females) aged 11.0 ± 4.7 years old. The most common aetiologies and fracture sites of patients were low falls (705, 65.4%) and humerus (492, 45.6%). A total of 146 (13.5%) patients suffered a nerve injury, 94 (8.7%) patients sustained associated injuries, and 106 (9.8%) patients sustained complications. The proportion of injuries due to motor vehicle collisions increased with increasing age and year of admission. Female patients presented with significantly higher proportion of injuries due to motor vehicle collisions and significantly lower proportion of injuries due to hit by others. The proportion decreased from 63.2% to 33.3% in humeral fracture, increased from 8.8% to 35.5% in radius fracture, increased from 7.4% to 28.9% in ulna fracture with increasing age. Female patients presented with significantly higher proportion of humeral fracture, clavicle fracture and significantly lower proportion of radius fracture, ulna fracture, and hand fracture. Low falls and humerus fractures were the most common aetiologies and fracture sites. The pattern of traumatic upper limb fractures has specific age, gender, time, and etiology differences.

Epidemiologic Features of Traumatic Fractures in Children and Adolescents: A 9-Year Retrospective Study

Purpose

Fractures are common among all types of paediatric injuries, with differences in incidence over time. Here, we present the epidemiologic features of traumatic fractures in a population of youth ≤ 18 years of age who were admitted to our university-affiliated hospitals from 2002 to 2010.

Methods

We retrospectively reviewed 2450 children and adolescents who had traumatic fractures. The data include variables such as age, sex, date of injury, and the mechanism of injury. For the period of 2002-2010, there were 2450 injury events that resulted in at least 1 fracture.

Results

Low falls (1042, 42.5%) and upper limb fractures (1068, 43.6%) were the most common aetiologies and fracture sites. With increasing age, the proportion of injuries due to motor vehicle collisions (MVCs) decreased and the injuries due to being hit by others and due to sprains increased. With increasing age, the proportion of craniofacial fractures (CFFs) decreased, and lower limb fractures (LLFs), spinal fractures (SFs), and fractures of ribs and the sternum (RSFs) increased. Over time, the proportion of injuries due to MVCs and mechanical injury decreased. Male patients presented with a significantly higher proportion of injuries due to low falls, being struck by an object, being hit by others, and due to sprains. There were a significantly lower proportion of injuries due to MVCs in female patients. Male patients presented with a significantly higher proportion of ULFs in the ≤6-year-old age group and a significantly lower proportion of LLFs and SFs in the 12-18-year-old age group than did female patients.

Conclusions

Low falls and upper limb fractures were the leading cause and fracture sites. To further improve the prevention and treatment of traumatic fractures in children and adolescents, policy makers should pay attention to these characteristics.

Traumatic Facial Fractures in Children and Adolescents

This study showed a retrospective analysis of the incidence and pattern of traumatic facial fractures in a pediatric and adolescent population (≤18 years old) in China. The authors retrospectively reviewed 154 children and adolescent who had traumatic facial fractures and who were admitted to our university-affiliated hospitals from 2005 to 2010. This study enrolled 109 males and 45 females aged 11.9 ± 5.2 years old. The incidence peaked around the periods of 12 to 18 years in the male, ≤6 and 16 to 18 years in the female. The most common etiologies were motor vehicle collisions (MVCs) (60, 39.0%), followed by high fall (40, 26.0%), low fall (32, 20.8%). The most common fracture sites were mandible (78, 50.6%) and nose (33, 21.4%), followed by orbit (31, 20.1%). A total of 35 (22.7%) patients suffered neurological deficit. The patients in the 12 to 18 age range group accounted for the largest proportion of 54.5%. Fracture incidence showed peaks between the hours of 12:00 to 16:00 PM (33.7%), during the autumn season (30.5%) and on Friday to Sunday (50.0%). The most common etiology and fracture site were MVCs and mandible, respectively. Etiologies and patterns of traumatic facial fractures vary with age. Continued efforts toward injury prevention of traumatic facial fracture among the children and adolescents are warranted.

Age, gender, and etiology differences of sports-related fractures in children and adolescents: A retrospective observational study

To investigate the age, gender, and etiology differences of sports-related fractures in children and adolescents (6-18 years old).We retrospectively reviewed 410 child and adolescent patients (335 males and 75 females aged 13.5 ± 3.1 years old) with sports-related fractures admitted to our university-affiliated hospitals from 2001 to 2010. The incidence and pattern were summarized with respect to different age groups, genders, etiologies.Playing basketball (97, 23.7%) and running (90, 22.0%) were the most common etiologies. Radius (102, 24.9%) was the most common fracture site. The most common etiologies and fracture sites were biking (19.6%) and humerus fractures (28.0%) in the ≤12 age range group, playing basketball (34.0%) and radius fractures (26.2%) in the 12-15 age range group, playing basketball (31.7%) and radius fractures (23.0%) in the 15-18 age range group. The most common etiologies were playing basketball (27.5%) in the male group and running (24.0%) in the female group. The male presented with significantly higher rate of radius fractures and nerve injury, significantly lower rate of femoral fractures than the female. The most common fracture sites were radius fractures in the basketball group (28.9%) and cricket group (37.5%), humerus fracture in the running group (20.0%), biking group (23.3%), and climbing group (45.0%), tibia fractures in the football group (28.9%) and playing SP bars group (50.0%), and ulna fractures (37.5%) in the ice skating group.Sports-related fractures are common in children and adolescents, particularly in males. Basketball, running, and biking were the most common etiologies; radius, ulna, and humerus were the most common fracture sites.

The optimal dosage regimen of vitamin D supplementation for correcting deficiency in adolescents: a pilot randomized controlled trial

BACKGROUND/OBJECTIVES

Vitamin D deficiency is common in adolescents but the optimal dosage regimen for correcting deficiency is unknown. To test the safety and efficacy of two different vitamin D dosage regimens to correct vitamin D deficiency in adolescents.

SUBJECTS/METHODS

In this 12-month, double-blind, randomized placebo-controlled trial, 28 adolescents (serum 25 hydroxyvitamin D (25(OH)D) of 21 to 50 nmol/L) were randomly assigned to one of three groups: monthly (n = 9; vitamin D3 50,000 IU orally monthly plus three placebo tablets 3-monthly), 3-monthly (n = 9; 150,000 IU (3 × 50,000 IU tablets) 3-monthly and placebo orally monthly), or placebo (n = 10; placebo monthly and three placebo tablets 3-monthly). Serum 25(OH)D was measured at baseline, 3, 6 and 12 months.

RESULTS

Two participants withdrew after their baseline measurement from the 3-monthly group. At 12 months, one participant was deficient (≤50 nmol/L) in both the monthly and 3-monthly groups, whereas six out of ten in the placebo remained deficient (P = 0.055). At 12 months, the average serum 25(OH)D levels for the monthly, 3-monthly and placebo groups were 76.4, 64.7 and 49.7 nmol/L, respectively (P < 0.001 and P = 0.04 for differences between monthly and placebo groups and 3-monthly and placebo groups respectively, after adjustment for age, sex and seasonal variation). Adherence was 100% and adverse events were minor.

CONCLUSIONS

Both 50,000 IU monthly and 150,000 IU 3-monthly of vitamin D3 safely and effectively corrects vitamin D deficiency in adolescents. These data provide treatment options which can be used by health practitioners to tailor vitamin D dosage regiments according to patient preference and context.

Does vitamin D supplementation improve bone density in vitamin D-deficient children? Protocol for an individual patient data meta-analysis

INTRODUCTION

Our previous study-level (aggregate data) meta-analysis suggested that vitamin D supplements may be beneficial for bone density specifically in children with vitamin D deficiency. However, the misclassification of vitamin D status inherent in study-level data means that the results are not definitive and cannot provide an accurate assessment of the size of any effect. Therefore, we propose to undertake an individual patient data (IPD) meta-analysis to determine whether the effect of vitamin D supplementation on bone density in children differs according to baseline vitamin D status, and to specifically estimate the effect of vitamin D in children who are vitamin D deficient.

METHODS AND ANALYSIS

This study has been designed to adhere to the Preferred Reporting Items for Systematic Review and Meta-Analyses of IPD statement. We will include randomised placebo-controlled trials of vitamin D supplementation reporting bone density outcomes at least 6 months after the study commenced in children and adolescents (aged <20 years) without coexistent medical conditions or treatments causing osteoporosis. We will update the search of the original review to cover the period 2009-2017, using the same methods as the original review. Fully anonymised data on all randomised patients will be requested. Outcomes will be femoral neck, total hip, lumbar spine and proximal and distal forearm bone mineral density, and total body bone mineral content. A two-stage IPD meta-analysis will be used to examine the effect of baseline serum 25-hydroxyvitamin D (25(OH)D) on treatment effect for each bone density outcome. Restricted maximum likelihood will be used to estimate the random-effects meta-analysis models, with 95% CI for summary effects. Heterogeneity will be assessed by I2 and potential publication bias (small-study effects) and availability bias by funnel plots, Egger's test and Peter's test.

ETHICS AND DISSEMINATION

Ethics approval will not be required as the data are to be used for the primary purpose for which they were collected and all original individual studies had ethics approval. Results of the IPD meta-analysis will be submitted for publication in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42017068772.

Fracture Incidence and Characteristics in Young Adults Aged 18 to 49 Years: A Population-Based Study

Although fractures in both the pediatric and, especially, the elderly populations have been extensively investigated, comparatively little attention has been given to the age group in between. Thus, we used the comprehensive (inpatient and outpatient) data resources of the Rochester Epidemiology Project to determine incidence rates for all fractures among young adult (age range, 18 to 49 years) residents of Olmsted County, Minnesota, in 2009 to 2011, and compared the distribution of fracture sites and causes in this young adult cohort with those for older residents aged 50 years or older. During the 3-year study period, 2482 Olmsted County residents aged 18 to 49 years experienced 1 or more fractures. There were 1730 fractures among 1447 men compared with 1164 among 1035 women, and the age-adjusted incidence of all fractures was 66% greater among the men (1882 [95% confidence interval 1793-1971] versus 1135 [95% CI 1069-1201] per 100,000 person-years; p < 0.001). Of all fractures, 80% resulted from severe trauma (eg, motor vehicle accidents) compared with 33% in Olmsted County residents age ≥50 years who sustained a fracture in 2009 to 2011. Younger residents (aged 18 to 49 years), when compared with older residents (aged ≥50 years), had a greater proportion of fractures of the hands and feet (40% versus 18%) with relatively few fractures observed at traditional osteoporotic fracture sites (14% versus 43%). Vertebral fractures were still more likely to be the result of moderate trauma than at other sites, especially in younger women. In conclusion, whereas pediatric and elderly populations often fracture from no more than moderate trauma, young adults, and more commonly men, suffer fractures primarily at non-osteoporotic sites due to more significant trauma. © 2017 American Society for Bone and Mineral Research.

Traumatic fractures as a result of falls in children and adolescents: A retrospective observational study

The aim of this study is to investigate the incidence and pattern of traumatic fractures (TFs) as a result of falls in a population of children and adolescents (≤18 years old) in China.This was a cross-sectional study. We retrospectively reviewed 1412 patients who were children and adolescents with TFs as a result of falls admitted to our university-affiliated hospitals in China from 2001 to 2010. Etiologies included high fall (height ≥2) and low fall (height <2 m). The incidence and pattern were summarized with respect to different age groups, year of admission, etiologies, genders, and the neurological function.This study enrolled 1054 males (74.6%) and 358 females (25.4%) aged 10.8 ± 4.7 years. The etiologies were low fall (1059, 75.0%) and high fall (353, 25.0%). There were 2073 fractures in total and 92 patients (6.5%) presented with multiple fractures. The most common fracture sites were upper extremity fractures in 814 patients (57.6%) and lower extremity fractures in 383 patients (27.1%), followed by craniofacial fractures in 233 patients (16.5%). A total of 231 (16.4%) patients suffered a nerve injury. The frequencies of early and late complications/associated injuries were 19.5% (n = 275) and 9.2% (n = 130). The frequencies of emergency admission, nerve injury, spinal fracture, lower extremity fractures, craniofacial fracture, sternum and rib fracture, and early complications/ASOIs were significantly larger in high fall than low fall (all P <.001, respectively). The frequencies of medical insurance rate (P = .042) and upper extremity fractures (P <.001) were significantly larger in low fall than high fall. The frequencies of spinal fracture (P = .039), lower extremity fractures (P = .048), and craniofacial fracture (P = .041) were significantly larger in female than the male patients. The frequency of upper extremity fractures (P <.001) and the mean age (P <.001) was significantly larger in male than female patients. The frequencies of emergency admission, high fall, spinal fracture, and craniofacial fracture were significantly larger in patients with nerve injury than other patients without nerve injury (all P <.001, respectively).Low falls and upper extremity fractures were the most common etiologies and sites, respectively. High fall, spinal fracture and craniofacial fracture were risk factors for nerve injury. Therefore, we should focus on patients who were caused by high fall and presented with spinal and craniofacial fracture to determine the presence of a nerve injury so that we can provide early, timely diagnosis and targeted treatment to children.

Fracture incidence rates in Norwegian children, The Tromsø Study, Fit Futures

This study describes childhood fracture rates in Norway, a country known for high fracture rates in the adult population. Fracture rates correspond with other reports from Scandinavia, although with a slightly higher proportion in girls. Indications of increased vulnerability during stages of puberty require further exploration.

INTRODUCTION

Fractures are common injuries during childhood. Incidence rates and patterns vary, but population-based data are scarce. The aim of this study was to describe the sex-, age- and maturation-specific incidence of fractures in a representative population-based sample from a region in Norway.

METHODS

All fractures in the population based convenient cohort Fit Futures, comprising 961 adolescents under 18 years, were recorded retrospectively from the local hospital. Details on individual's age and fracture site were recorded. A radiologist confirmed all fractures.

RESULTS

In the period from birth to cohort scanning, the register recorded 316 fractures in 253 individuals. Fractures were more common in boys (35%) than in girls (31%). The overall annual fracture incidence was 204 per 10,000 persons-year under the age of 18 and 205 under the age of 16. The majority of fractures involved the upper extremities and the most common site of fracture was the forearm with 24% of the fractures followed by phalanges with 23% of the fractures. Fractures peaked in girls at sexual maturation stage 3. Boys had a peak in stage 2. Timing of subsequent fractures was also consistent with stages of sexual maturation.

CONCLUSIONS

The overall incidence of fractures in childhood in Northern Norway corresponds with other reports from Scandinavia, although the proportion of fractures in girls is higher than in other studies. Both sexes seem especially vulnerable at stages related to sexual maturation. Whether this reflects bone vulnerability or other changes related to puberty requires further investigation.

Fracture in Duchenne Muscular Dystrophy: Natural History and Vitamin D Deficiency

The present study examined the natural history of fracture and vitamin D levels in Duchenne muscular dystrophy patients, who are vulnerable to osteoporosis and fractures. Retrospective analysis of a cohort of 48 Duchenne muscular dystrophy patients revealed that 43% of patients experienced ≥1 fracture. Fracture probabilities at ages 6, 9, 12, and 15 years were 4%, 9%, 31%, and 60% respectively, accelerating around the time of ambulation loss (mean age 11.8 ± 2.7 years). Chronic corticosteroid therapy was utilized in 69% of patients and was associated with all vertebral fractures. A history of vitamin D deficiency occurred in 84%, and 35% were currently deficient. Despite chronic vitamin D supplementation, 38% remained deficient. These results demonstrate that osteoporosis and fracture remain major concerns in Duchenne muscular dystrophy. Bone health should be optimized well before loss of ambulation, however current levels of vitamin D supplementation may be inadequate given high levels of deficiency.

The Effect of Age on Fracture Risk: A Population-Based Cohort Study

Aim. To precisely estimate the effect of age on the risk of fracture hospitalisation among the Western Australia population over the life course. Methods. This population-based cohort study used hospital data on fractures for the period January 1991 to January 2013 among Western Australians born between 1915 and 1990. Results. The average incidence rates (per 10,000 person-years) of fracture hospitalisation (95% confidence interval) were 50.12 (49.90, 50.35), 55.14 (54.82, 55.48), and 45.02 (44.71, 45.32) for both males and females, males only, and females only, respectively. The age-specific rate of fracture hospitalisation (in natural logarithm form) in adults (>18 years) was well predicted by age at its 1st, 2nd, and 3rd power in males with an adjusted R-squared of 0.98 and p < 0.001. For females, the trend was also well predicted by its 1st and 2nd powers (the 3rd power term of age was removed due to its p value > 0.8) with an adjusted R-squared of 0.99 and p < 0.001. Conclusions. Overall trends in age and gender specific risk of fracture among the Western Australian population were similar to estimates reported from previous studies. The trend in fracture hospitalisation risk over the life course can be almost fully explained by age.

High prevalence of vitamin D deficiency in 2-17 year olds presenting with acute fractures in southern Australia

AIM

To determine vitamin D deficiency risk and other lifestyle factors in children aged 2-17 years presenting with an acute fracture to Sunshine Hospital.

METHODS

A prospective observational study was undertaken using a convenience sample data collected from children aged 2-17 years of age presenting with an acute fracture. Recruitment was undertaken over a 3-month period from February to May 2014. Risk factors for vitamin D deficiency (skin pigmentation, hours spent outdoors, sunscreen use and obesity) were identified. Patients providing consent, had measurements of serum 25-hydroxyvitamin D (25-OHD). Vitamin D deficiency was defined as < 50 nmol/L.

RESULTS

Of the 163 patients recruited into this study, 134 (82%) had one or more risk factor(s) for vitamin D deficiency. Of these, 109 (81%) consented to 25-OHD testing, with a median of 53 nmol/l (range 14-110 nmol/l) obtained. A total of 57 (52% at risk, 35% of total participants) were found to be vitamin D deficient. 45 (80%) had mild deficiency (30-50 nmol/l) and 11 (20%) had moderate deficiency (12.5-29 nmol/l).

CONCLUSIONS

One third of all participants, and the majority participants who had one or more risk factor(s) for vitamin D deficiency, were vitamin D deficient. Based on our findings we recommend that vitamin D status be assessed in all children with risk factor of vitamin D deficiency living in urban environments at higher latitudes presenting with fractures. The effect of vitamin D status on fracture risk and fracture healing in children and teenagers is yet to be determined, as do the effects of vitamin D supplementation in vitamin D deficient paediatric patients presenting with acute fracture.

Association between duration of playing video games and bone mineral density in Chinese adolescents

The aim of the study was to investigate the association between duration of playing video games and bone mineral density (BMD) in Chinese adolescents. Three hundred eighty-four Chinese adolescents aged 14-18 yr (148 males and 236 females) were analyzed. Anthropometric measurements were obtained using standard procedures. Total body and regional BMD were measured using dual-energy X-ray absorptiometry. Duration of playing video games, defined as hours per day, was measured by a self-report questionnaire. We examined the association between duration of playing video games and BMD using multiple linear regression analysis. After adjustment for age, sex, pubertal stage, parental education, body mass index, adolescents with longer video game duration were more likely to have lower legs, trunk, pelvic, spine, and total BMD (p < 0.05). We concluded that duration of video game was negatively associated with BMD in Chinese adolescents. These findings provide support for reducing duration of playing video games as a possible means to increase BMD in adolescents. Future research is needed to elucidate the underlined mechanisms linking playing video games and osteoporosis.

Bone status in patients with epilepsy: relationship to markers of bone remodeling

Patients with epilepsy and treated with antiepileptic drugs (AEDs) may develop metabolic bone disease; however, the exact pathogenesis of bone loss with AEDs is still unclear. Included were 75 adults with epilepsy (mean age: 31.90 ± 5.62 years; duration of treatment with AEDs: 10.57 ± 3.55 years) and 40 matched healthy controls. Bone mineral content (BMC) and bone mineral densities (BMD) of the femoral neck and lumbar spine were measured using dual-energy X-ray absorptiometry (DEXA). Blood samples were analyzed for calcium, magnesium, phosphate, alkaline phosphatase (ALP), 25-hydroxy vitamin D (25OHD), soluble receptor activator of nuclear factor-kappa B ligand (sRANKL), osteoprotegerin (OPG), and OPG/RANKL ratio (markers of bone remodeling). Compared to controls, patients had lower BMD, BMC, Z-score, and T-score at the femoral neck and lumbar spine (all p < 0.001). Seventy-two percent and 29.33% of patients had osteoporosis of the lumbar spine and femoral neck. Patients had significantly lower serum calcium, 25(OH)D, and OPG and higher ALP, sRANKL levels, and sRANKL/OPG (all p < 0.001). Fifty-two percent of patients had hypocalcemia, 93% had hypovitaminosis D, 31% had high levels of sRANKL, and 49% had low levels of OPG. No differences were identified between DEXA and laboratory results in relation to the type, dose, or serum levels of AEDs. BMD at the femoral neck and lumbar spine were found to be correlated with the duration of illness (p = 0.043; p = 0.010), duration of treatment with AEDs (p < 0.001; p = 0.012), and serum levels of 25(OH)D (p = 0.042; p = 0.010), sRANKLs (p = 0.005; p = 0.01), and OPG (p = 0.006; p = 0.01). In linear regression analysis and after adjusting for gender, age, weight, duration, and number of AEDs, we observed an association between BMD, 25(OH)D (p = 0.04) and sRANKL (p = 0.03) concentrations. We conclude that AEDs may compromise bone health through disturbance of mineral metabolism and acceleration of bone turnover mechanisms.

Vitamin D and bone health in childhood and adolescence

Vitamin D plays a key role in bone metabolism. The link between vitamin D deficiency and rickets is well understood. However, subclinical vitamin D deficiency may also be detrimental to bone health in childhood. Its effects on bone mineralization have the potential to result in lower peak bone mass being attained, which could in turn contribute to increased fracture risk in both childhood and older adult life. As vitamin D deficiency is common globally, any detrimental effects of vitamin D deficiency on bone health are likely to have substantial public health implications. This review describes the current literature relevant to vitamin D and bone health in childhood and adolescence, with a particular emphasis on evaluating the emerging evidence for the impact of subclinical vitamin D deficiency on bone health and the effectiveness of vitamin D supplementation. The evidence suggests that subclinical vitamin D deficiency does affect bone acquisition, potentially beginning in utero and extending into adolescence. However, the effectiveness of vitamin D supplementation for improving bone health in situations of subclinical deficiency remains unclear, particularly in early life where there are few trials with bone density outcomes. The available evidence suggests that benefits are likely to be greatest in or even restricted to children with serum 25-hydroxyvitamin D levels at least below 50 nmol/L and possibly even lower than this. Trials of sufficient duration in deficient pregnant mothers, infants, and children are urgently required to address critical evidence gaps.

Reporting of lifetime fractures: methodological considerations and results from the Thai Cohort Study

OBJECTIVES

To provide estimates of fracture incidence among young adults in Thailand.

DESIGN

Cross-sectional analysis of a large national cohort.

SETTING

Thailand.

PARTICIPANTS

A total of 60 569 study participants residing nationwide responded to the 2009 follow-up survey; 55% were women and median age was 34 years (range 19-92).

OUTCOME MEASURES

Self-reported lifetime fractures, along with age at fracture. Fracture incidence rates per person-year were then compared using lifetime fracture reports, and again selecting only fractures reported for the last year. Incidence rates were compared by age and sex.

RESULTS

18 010 lifetime fractures were reported; 11 645(65%) by men. Lifetime fracture prevalence was 30% for men and 15% for women. Lifetime incidence per 10 000 person-years was 83; analysing only fractures from the last year yielded a corresponding incidence rate of 187. For ages 21-30, fractures per 10 000 person-years were more common among men than women (283 (95% CI 244 to 326) and 150 (130 to 173), respectively); with increasing age, rates decreased among men and increased among women (for ages 51-60, 97 (58 to 151) and 286 (189 to 417), respectively).

CONCLUSIONS

Large-scale surveys provide a feasible method for establishing relative fracture incidence among informative subgroups in a population. Limiting analyses to fractures reported to have occurred recently minimises bias due to poor recall. The pattern of self-reported fracture incidence among Thais aged 20-60 was similar to that reported for Western countries: high falling rates in young men and high rising rates in older women.

Mineral metabolism markers and the long-term risk of hip fracture: the cardiovascular health study

CONTEXT

Disturbances in mineral metabolism are associated with lower bone mineral density and fracture; however, previous human studies have assessed individual mineral metabolism markers in isolation.

OBJECTIVE

We assessed serum concentrations of 25-hydroxyvitamin D (25-OHD), PTH, and bone-specific alkaline phosphatase (BAP) concentrations individually, and in combination, in association with the long-term risk of hip fracture among a general population of older adults.

DESIGN AND SETTING

We studied 2294 participants from the Cardiovascular Health Study (mean age 74 yr) who were ambulatory and free of hip fracture and known cardiovascular disease at baseline. We used proportional hazards models to evaluate associations of baseline serum 25-OHD, PTH, and BAP concentrations with the time to first hospitalized hip fracture.

RESULTS

During a median of 13 yr of follow-up, 242 participants (10.6%) developed an incident hip fracture. Serum 25-OHD concentrations less than 15 ng/ml were associated with a 61% greater adjusted risk of fracture (95% confidence interval 12-132% greater). In contrast, neither serum PTH nor BAP concentrations were significantly associated with fracture risk. The association of 25-OHD deficiency with hip fracture was not significantly altered by either PTH or BAP concentrations.

CONCLUSIONS

Serum concentrations of 25-OHD, but not PTH or BAP, are associated with long-term hip fracture risk among ambulatory older adults. These data suggest that 25-OHD is the most relevant mineral metabolism marker of fracture risk among older people.

Influences of bone and mineral metabolism in epilepsy

INTRODUCTION

Patients with epilepsy are at increased risk for metabolic bone disease, low bone mineral density and fractures.

AREAS COVERED

This article reviews the predictors and mechanisms of bone loss in patients with epilepsy. It provides information regarding the basic bone biology, evidences of osteopathy with epilepsy and the potential mechanisms of its pathogenesis. This review shows that long-term use of antiepileptic drugs (AEDs) is associated with the risk of osteopathy. However, age, gender, low body mass, severity of epilepsy, co-morbid conditions, institutionalization and calcium and vitamin D deficiencies are additional and modified risk factors. AEDs may indirectly accelerate bone loss through hypovitaminosis D, hypocalcemia and hyperparathyroidism or reduce bone accrual through decreasing the levels of calcitonin, growth factors and vitamin K. Also, AEDs may directly accelerate osteoclastic (bone loss) and/or reduce osteoblastic (bone formation) activities, the main cells involved in bone remodeling.

EXPERT OPINION

Understanding the basic bone biology and the pathophysiology of the disturbed bone and mineral metabolism in epilepsy will aid in identification and monitoring of patients at risk and in planning appropriate prophylactic and therapeutic measures.

Decreasing incidence and changing pattern of childhood fractures: A population-based study

Fractures are common in children, and some studies suggest an increasing incidence. Data on population-based long-term trends are scarce. In order to establish fracture incidence and epidemiologic patterns, we carried out a population-based study in Helsinki, Finland. All fractures in children aged 0 to 15 years were recorded from public health care institutions during a 12-month period in 2005. Details regarding patient demographics, fracture site, and trauma mechanism were collected. All fractures were confirmed from radiographs. Similar data from 1967, 1978, and 1983 were used for comparison. In 2005, altogether 1396 fractures were recorded, 63% in boys. The overall fracture incidence was 163 per 10,000. Causative injuries consisted of mainly falls when running or walking or from heights less than 1.5 m. Fracture incidence peaked at 10 years in girls and 14 years in boys. An increase in fracture incidence was seen from 1967 to 1983 (24%, p < .0001), but a significant decrease (18%, p < .0001) was seen from 1983 to 2005. This reduction was largest in children between the ages of 10 and 13 years. Despite the overall decrease and marked decrease in hand (-39%, p < .0001) and foot (-48%, p < .0001) fractures, the incidence of forearm and upper arm fractures increased significantly by 31% (p < .0001) and 39% (p = .021), respectively. Based on these findings, the overall incidence of childhood fractures has decreased significantly during the last two decades. Concurrently, the incidence of forearm and upper arm fractures has increased by one-third. The reasons for these epidemiologic changes remain to be elucidated in future studies.

Overweight children have a greater proportion of fat mass relative to muscle mass in the upper limbs than in the lower limbs: implications for bone strength at the distal forearm

BACKGROUND

The influence of adiposity on upper-limb bone strength has rarely been studied in children, despite the high incidence of forearm fractures in this population.

OBJECTIVE

The objective was to compare the influence of muscle and fat tissues on bone strength between the upper and lower limbs in prepubertal children.

DESIGN

Bone mineral content, total bone cross-sectional area, cortical bone area (CoA), cortical thickness (CoTh) at the radius and tibia (4% and 66%, respectively), trabecular density (TrD), bone strength index (4% sites), cortical density (CoD), stress-strain index, and muscle and fat areas (66% sites) were measured by using peripheral quantitative computed tomography in 427 children (206 boys) aged 7-10 y.

RESULTS

Overweight children (n = 93) had greater values for bone variables (0.3-1.3 SD; P < 0.0001) than did their normal-weight peers, except for CoD 66% and CoTh 4%. The between-group differences were 21-87% greater at the tibia than at the radius. After adjustment for muscle cross-sectional area, TrD 4%, bone mineral content, CoA, and CoTh 66% at the tibia remained greater in overweight children, whereas at the distal radius total bone cross-sectional area and CoTh were smaller in overweight children (P < 0.05). Overweight children had a greater fat-muscle ratio than did normal-weight children, particularly in the forearm (92 +/- 28% compared with 57 +/- 17%). Fat-muscle ratio correlated negatively with all bone variables, except for TrD and CoD, after adjustment for body weight (r = -0.17 to -0.54; P < 0.0001).

CONCLUSIONS

Overweight children had stronger bones than did their normal-weight peers, largely because of greater muscle size. However, the overweight children had a high proportion of fat relative to muscle in the forearm, which is associated with reduced bone strength.

Early determinants of fractures in Rett syndrome

OBJECTIVES

The goals were to compare the fracture incidence in Rett syndrome with that in the general population and to investigate the impact of genotype, epilepsy, and early motor skills on subsequent fracture incidence in girls and young women with Rett syndrome.

METHODS

The Australian Rett syndrome study, a population-based study operating since 1993, investigated Australian subjects with Rett syndrome born since 1976. The 234 (81.2%) of 288 verified cases in the Australian Rett syndrome database in 2004 whose families had completed follow-up questionnaires and provided information about fracture history were included in the analyses. The main outcomes were fracture incidence in the Rett syndrome population and fracture risk according to genotype, presence of epilepsy, and early motor profile.

RESULTS

Fracture incidence in this cohort was 43.3 episodes per 1000 person-years, nearly 4 times greater than the population rate. Risk was increased specifically in cases with p.R270X mutations and in cases with p.R168X mutations. Having epilepsy also increased fracture risk, even after adjustment for genotype.

CONCLUSIONS

Girls and young women with Rett syndrome are at increased risk of fracture. Those with mutations found previously to be more severe and those with epilepsy have an increased propensity toward fractures. Improved understanding of the risk factors for fracture could contribute to better targeting of interventions to decrease fracture incidence in this vulnerable population.

Which bone mass measures discriminate adolescents who have fractured from those who have not?

This study of 415 adolescent children examined the association between four different measures of bone mass and prevalent fracture (N = 160 children). DXA measures and calcaneal ultrasound (but not radial ultrasound or metacarpal index) were associated with upper limb fracture, suggesting heel ultrasound is also a discriminator of fractures in children.

INTRODUCTION

The aim of the study was to describe the association between different measures of bone mass and prevalent fracture in adolescents.

METHODS

A total of 415 adolescents (150 girls and 265 boys), mean age 16.3 years were examined. Dual energy X-ray absorptiometry (DXA) measures were performed at hip, spine, radius and total body. Calcaneal bone ultrasound attenuation (BUA), speed of sound (SOS), and stiffness were assessed by a Sahara densitometer. Radial ultrasound SOS was assessed by a Sunlight 8000P machine. Metacarpal index was calculated from a left hand X-ray. Prevalent fractures were assessed by questionnaire.

RESULTS

A total of 160 adolescents (39%) reported at least one previous fracture (106 upper limb, 53 lower limb, one other for first fracture). Significantly lower DXA measures, heel BUA, and heel stiffness was observed in those with a history of upper limb fracture (all P < 0.05). Despite significant correlations between all the bone mass measures, radial ultrasound and metacarpal index did not discriminate those with fracture from those without. Similar associations were present for number of fractures. No bone measure was able to discriminate lower limb fracture.

CONCLUSIONS

Both calcaneal quantitative ultrasound and DXA are able to discriminate adolescents with a history of upper limb fracture from those without.

Determinants of skeletal age deviation in a cross-sectional study

OBJECTIVE

Skeletal age deviation (SAD) is associated with bone mass and fracture risk in children, but factors determining this are unknown. The aim of this population-based cross-sectional study was to describe the factors associated with SAD.

METHODS

A convenience sample of 640 male and female children aged 7-17 yr was studied. All were assessed for body composition (dual-energy x-ray absorptiometry), diet, strength, dexterity, habitual physical activity, sunlight exposure, smoking, and medication use. Skeletal age was assigned using the Tanner-Whitehouse-2 method.

RESULTS

Subjects with a SAD greater than the 75th percentile had significantly higher height, weight, and Tanner stage compared with all other subjects. Bone-free lean mass, fat mass, and grip strength were positively associated with SAD. In multivariate analysis, ever smoking and use of inhaled corticosteroids were negatively associated with SAD, whereas milk drinking was positively associated with SAD. There was no significant association between sunlight exposure, television watching, light, or strenuous exercise and SAD.

CONCLUSIONS

The results of this study should be regarded as hypothesis generating but are biologically plausible and suggest that body composition, strength, diet, ever smoking, and inhaled corticosteroid use may be determinants of bone maturity relative to age and thus affect fracture risk in children. However, more studies are necessary to explore other determinants of SAD such as genetic and perinatal factors and whether SAD influences peak bone mass.

Can BMD assessed by DXA at age 8 predict fracture risk in boys and girls during puberty?: an eight-year prospective study

This study reports on the association between DXA at age 8 and subsequent fractures in both male and female children. Bone densitometry at the total body and spine (but not hip) is a strong predictor of fracture (especially upper limb) during puberty.

INTRODUCTION

The aim of this study was to determine if prepubertal DXA can predict fracture risk during puberty.

MATERIALS AND METHODS

We studied 183 children who were followed for 8 yr (1460 person-years). Bone densitometry was measured at the total body, hip, and spine by DXA and reported as BMC, BMD, and bone mineral apparent density (BMAD). Fractures were self-reported at age 16 with X-ray confirmation,

RESULTS

There were a total of 63 fractures (43 upper limb). In unadjusted analysis, only total body BMD showed an inverse relationship with upper limb fracture risk (p = 0.03). However, after adjustment for height, weight, age (all at age 8), and sex, total body BMC (HR/SD, 2.47; 95% CI, 1.52-4.02), spine BMC (HR/SD, 1.97: 95% CI, 1.30-2.98), total body BMD (HR/SD, 1.67; 95% CI, 1.18-2.36), total body BMAD (HR/SD, 1.54; 95% CI, 1.01-2.37), and spine BMD (HR/SD, 1.53; 95% CI, 1.10, 2.22) were all significantly associated with upper limb fracture risk. Similar, but weaker associations were present for total fractures. There was a trend for overweight/obesity to be associated with increased upper limb fracture risk (HR, 1.53/category; p = 0.08).

CONCLUSIONS

Measurement of bone mass by DXA is a good predictor of upper limb fracture risk during puberty. Although we did not measure true BMD, the constancy of fracture prediction after a single measure suggests bone strength remains relatively constant during puberty despite the large changes in bone size.

Pathological fractures in epilepsy

Fracture rates in epilepsy are two to three times that for the general population, although the influence of gender and age is not well defined. We examined, over a 7-year period at a single health care center, 750 patients with epilepsy who sustained the fractures. Among these patients, 293 (39%) had pathological fractures and 457 (61%) had traumatic/seizure-related fractures. Pathological fractures accounted for 71% of the 146 patients >60 years, a group traditionally at risk for pathological fractures (P<0.02). Fractures in epilepsy are distributed with bimodal peaks in the fifth and eighth decades of life, although pathological fractures are a significant contributor across the life span, accounting for 20 to 40% of patients traditionally thought not to be at risk for involutional osteoporotic fractures. Together these findings suggest that epilepsy, and/or its treatment, is a dominant influence in the pathogenesis of fractures and may exacerbate the effects of aging-related involutional osteoporosis.

The management of wrist injuries: an international perspective

Wrist injury is common and may significantly impair the overall function of the upper extremity unless properly managed. Fractures of the distal radius are particularly common among the aging population, accounting for nearly 1/6 of all fractures, often as a result of increased longevity with the subsequent underlying osteoporosis. New diagnostic tools, including wrist arthroscopy, magnetic resonance imaging, or computed tomography, are increasingly available in developed countries allowing accurate recognition and more effective resolution of lesions which would be otherwise missed using conventional methods. First world treatment standards, however, can scarcely be introduced in developing countries owing to, among other factors, different prevalence of problems, and the lack of resource to implement most modern technologies. If any program needs to be introduced that meets the demands of wrist injury management in the third world, aside from a better regionalisation of trauma care, it should emphasise adequate training of professionals in the use of more cost effective techniques of fracture reduction and stabilisation, applicable everywhere, with the minimum possible morbidity.

Effects of calcium supplementation on bone density in healthy children: meta-analysis of randomised controlled trials

OBJECTIVES

To assess the effectiveness of calcium supplementation for improving bone mineral density in healthy children and to determine if any effect is modified by other factors and persists after supplementation stops.

DESIGN

Meta-analysis.

DATA SOURCES

Electronic bibliographic databases, hand searching of conference proceedings, and contacting authors for unpublished data.

REVIEW METHODS

We included randomised placebo controlled trials of calcium supplementation in healthy children that lasted at least three months and had bone outcomes measured after at least six months of follow-up. Two reviewers independently extracted data and assessed quality. Meta-analyses predominantly used fixed effects models with outcomes given as standardised mean differences.

RESULTS

We included 19 studies involving 2859 children. Calcium supplementation had no effect on bone mineral density at the femoral neck or lumbar spine. There was a small effect on total body bone mineral content (standardised mean difference 0.14, 95% confidence interval 0.01 to 0.27) and upper limb bone mineral density (0.14, 0.04 to 0.24). This effect persisted after the end of supplementation only at the upper limb (0.14, 0.01 to 0.28). There was no evidence that sex, baseline calcium intake, pubertal stage, ethnicity, or level of physical activity modified the effect.

CONCLUSIONS

The small effect of calcium supplementation on bone mineral density in the upper limb is unlikely to reduce the risk of fracture, either in childhood or later life, to a degree of major public health importance.

Incidence and demographics of hand fractures in British Columbia, Canada: a population-based study

PURPOSE

To identify population-based hand fracture annual incidence rates, demographics, and seasonal and geographic variations from all patients seeking treatment for a hand fracture in British Columbia, Canada from May 1, 1996 to April 20, 2001.

METHODS

All Medical Service Plan and Hospital Separation records that included International Classification of Diseases-9 codes for metacarpal (815), phalangeal (816), and multiple (817) fractures were extracted from the British Columbia Linked Health Dataset, along with the individual registry demographic records linked to each hand fracture.

RESULTS

A total of 72,481 hand fractures were identified. Fifty percent were phalangeal fractures, 42% were metacarpal fractures, and 8% were multiple fractures. The total population annual incidence rate for a hand fracture was 36 per 10,000. Age-adjusted annual incidence rates ranged from 29 per 10,000 for people older than 20 years to 61 per 10,000 for people age 20 or younger. The most common age for a hand fracture was 14 years for males and 13 years for females. Males had a 2.08 greater relative risk for hand fracture and they maintained most of this increase in risk between the ages of 15 and 40. For females there was an increased relative risk for a hand fracture after the age of 65. Spring had the highest rates for hand fractures. People in the Northern half of the province had a 1.6 greater relative risk for sustaining a hand fracture, compared with people in the more urbanized, less-industrialized, and more-affluent Southwestern region.

CONCLUSIONS

Our study provides a robust projection of annual incidence rates for hand fractures because we were able to review all occurrences of a hand fracture within a population base of approximately 4 million people over a 5-year period. Our study also allowed for the examination of how age, gender, season, and geographic location influenced hand fracture incidence rates within a large, diverse population.

Calcium supplementation for improving bone mineral density in children

BACKGROUND

Clinical trials have shown that calcium supplementation in children can increase bone mineral density (BMD) although this effect may not be maintained. There has been no quantitative systematic review of this intervention.

OBJECTIVES

. To determine the effectiveness of calcium supplementation for improving BMD in children. . To determine if any effect varies by sex, pubertal stage, ethnicity or level of physical activity, and if any effect persists after supplementation is ceased.

SEARCH STRATEGY

We searched CENTRAL, (Cochrane Central Register of Controlled Trials) (Issue 3, 2005), MEDLINE (1966 to 1 April 2005), EMBASE (1980 to 1 April 2005), CINAHL (1982 to 1 April 2005), AMED (1985 to 1 April 2005), MANTIS (1880 to 1 April 2005) ISI Web of Science (1945 to 1 April 2005), Food Science and Technology Abstracts (1969 to 1 April 2005) and Human Nutrition (1982 to 1 April 2005). Conference abstract books (Osteoporosis International, Journal of Bone and Mineral Research) were hand-searched.

SELECTION CRITERIA

Randomised controlled trials of calcium supplementation (including by food sources) compared with placebo, with a treatment period of at least 3 months in children without co-existent medical conditions affecting bone metabolism. Outcomes had to include areal or volumetric BMD, bone mineral content (BMC), or in the case of studies using quantitative ultrasound, broadband ultrasound attenuation and ultrasonic speed of sound, measured after at least 6 months of follow-up.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data including adverse events. We contacted study authors for additional information.

MAIN RESULTS

The 19 trials included 2859 participants, of which 1367 were randomised to supplementation and 1426 to placebo. There was no heterogeneity in the results of the main effects analyses to suggest that the studies were not comparable. There was no effect of calcium supplementation on femoral neck or lumbar spine BMD. There was a small effect on total body BMC (standardised mean difference (SMD) +0.14, 95% CI+0.01, +0.27) and upper limb BMD (SMD +0.14, 95%CI +0.04, +0.24). Only the effect in the upper limb persisted after supplementation ceased (SMD+0.14, 95%CI+0.01, +0.28). This effect is approximately equivalent to a 1.7% greater increase in supplemented groups, which at best would reduce absolute fracture risk in children by 0.1-0.2%per annum. There was no evidence of effect modification by baseline calcium intake, sex, ethnicity, physical activity or pubertal stage. Adverse events were reported infrequently and were minor.

AUTHORS' CONCLUSIONS

While there is a small effect of calcium supplementation in the upper limb, the increase in BMD which results is unlikely to result in a clinically significant decrease in fracture risk. The results do not support the use of calcium supplementation in healthy children as a public health intervention. These results cannot be extrapolated to children with medical conditions affecting bone metabolism.

Bone density interpretation and relevance in Caucasian children aged 9-17 years of age: insights from a population-based fracture study

The interpretation of bone density measurement in children is difficult due to a number of factors including rapid change in body size and uncertain clinical significance of bone density in children. This study asked two questions. (1) Is there a preferred bone density measurement site or type for fracture risk in children? (2) What is the best way to interpret bone density in children? This population-based case control study included 321 upper limb fracture cases and 321 class- and sex- matched randomly selected controls. Bone density at the hip, spine, and total body (including the arm) was measured by a Hologic QDR2000 densitometer (Waltham, MA) and examined as bone area (BA), bone mineral content (BMC), bone mineral density (BMD), bone mineral apparent density (BMAD), and BMC/lean mass (BMCLM). The only dual-energy X-ray absorptiometry (DXA) variables that were consistently associated with fracture risk in both boys and girls were spine BMD and BMAD for total upper limb fractures, and spine and hip BMAD for wrist and forearm fractures. No significant associations were observed for BA and BMCLM and inconsistent associations for BMC and other BMD sites. Five-yr fracture risk varied from 15-24% depending on site and gender in a child with a Z-score of -3. In the controls, all DXA variables were associated with age, height, and weight, but the weakest associations were with BMAD. In conclusion, in this study the spine BMAD had the strongest and most consistent association with upper limb fracture risk in children. The associations with age and body size imply that age specific Z-scores will be the most convenient for interpretation of DXA measures in children. Five-yr wrist and forearm fracture risk has potential as a clinical endpoint of immediate relevance.

Children who experience their first fracture at a young age have high rates of fracture

Rate of fracture was examined according to age at first fracture in 313 New Zealand children (145 girls, 168 boys) under l3 years of age (95.4% of a consecutive series of children treated at one hospital for a recent confirmed fracture at any site). In their lifetimes they had experienced 468 separate fracture events, over half (54.7%) occurring in the 32.3% of children breaking bones on more than one occasion. Children experiencing a first fracture before 4 years of age had 36.7 (95%CI 30.7-44.1) fractures per l00 years of exposure: this was a significantly higher rate than that of children experiencing their first fracture later in life. Thus, using the <4.0 year age group as a reference, we found that rate ratios (adjusted for gender) for groups that had suffered the first fracture at later ages were: first fracture between 4.0 and 6.99 years, 0.77 (95%CI 0.58-1.03); first fracture between 7.0 and 9.99 years, 0.63 (95%CI 0.42-0.94); first fracture between 10.0 and 12.99 years, 0.48 (95% CI 0.32-0.72). Asthma was over-represented (31% seen, 25% expected), and a high proportion of the sample (32.9%) used corticosteroid medications; however, neither characteristic affected age at first fracture. In contrast, the large number (n= 42) of youngsters (13.4% of the sample) reporting adverse reactions to milk were younger at first fracture than children without reactions to milk (P<0.05). We conclude that children experiencing their first fracture at a young age have high rates of fracture and should be targeted for advice to improve their bone strength.

Identification of high-risk individuals for hip fracture: a 14-year prospective study

In this 14-year prospective study, men and women were found to share a common set of risk factors for hip fracture: low BMD, postural instability and/or quadriceps weakness, a history of falls, and prior fracture. The combination of these risk factors accounted for 57% and 37% of hip fractures in women and men, respectively.

INTRODUCTION

Risk factors for hip fracture, including low BMD, identified in women, have not been shown to be useful in men. It is also not known whether fall-related factors (muscle strength and postural instability) predict hip fracture. This study examined the association between falls-related factors and hip fractures in elderly men and women.

MATERIALS AND METHODS

This is an epidemiologic, community-based prospective study, which included 960 women and 689 men > or = 60 years of age who have been followed for a median of 12 years (interquartile range, 6-13). The number of person-years was 9961 for women and 4463 for men. The outcome measure was incidence of hip fracture. Risk factors were femoral neck BMD (FNBMD), postural sway, quadriceps strength, prior fracture, and fall.

RESULTS

Between 1989 and 2003, 115 (86 women) sustained a hip fracture. The risk of hip fracture (as measured by hazards ratio [HR]) was increased by 3.6-fold (95% CI: 2.6-4.5) in women and 3.4-fold (95% CI: 2.5-4.6) in men for each SD (0.12 g/cm2) reduction in FNBMD. After adjusting for BMD, the risk of hip fracture was also increased in individuals with the highest tertile of postural sway (HR: 2.7; 95% CI: 1.6-4.5) and low tertiles of quadriceps strength (HR: 3.0; 95% CI: 1.3-6.8). Furthermore, a history of fall during the preceding 12 months and a history of fracture were independent predictors of hip fracture. For each level of BMD, the risk of hip fracture increased linearly with the number of non-BMD risk factors. Approximately 57% and 37% of hip fracture cases in women and men, respectively, were attributable to the presence of risk factors, osteoporosis (BMD T score < or = -2.5), and advancing age.

CONCLUSIONS

Men and women had a common set of risk factors for hip fracture: low BMD, postural instability and/or quadriceps weakness, a history of falls, and prior fracture. Preventive strategies should simultaneously target reducing falls and improvement of bone strength in both men and women.

The characteristics of fractures in Polish adolescents aged 16-20 years

The aim of the study was to identify associations between fractures in childhood and family, anthropometric and lifestyle factors. Among 1,246 subjects aged 16.3-20.6 years (539 boys, 707 girls), based on a questionnaire, 869 were fracture-free while 377 (30.26%) had fractures. Of those reporting fractures, 146 reported multiple fractures (12% of studied population, 39% of all fractures). More boys had fractures than girls (35.6% vs 24.9%, p < 0.001). Fracture sites included: forearm (37%), fingers (23%) wrist (16%), ankle (14%), humerus (10%), tibia (8%) clavicle (7%) and femoral shaft / neck (3%). Among adolescents with multiple fractures, 52% also reported fractures in at least one family member, compared with 29% of those without a fracture history. Fractures in siblings and mothers (but not fathers) accounted for 44% of the liability in adolescents' fractures. Subjects with multiple fractures reported more time at the computer than those without fractures and reported more time participating in team sports, and 18.6% avoided milk, whereas 12.4% of those without fractures reported milk-free diets. Using a logistic regression model, none of the lifestyle factors, except for computer use, were independently associated with fractures. Fractures, particularly multiple fractures, are common in childhood and adolescence. Familial clustering of fractures suggests shared genetic and environmental factors are responsible.

Vitamin D insufficiency in adolescent males in Southern Tasmania: prevalence, determinants, and relationship to bone turnover markers

There are limited data on vitamin D insufficiency in healthy children. The aim of this study was to describe the prevalence and determinants of vitamin D insufficiency and its association with bone turnover in adolescent boys (N = 136, mean age 16 years). Sun exposure and physical activity were assessed by questionnaire. Vitamin D stores were assessed by serum 25-hydroxyvitamin D3 (25[OH]D3). Bone turnover was assessed by bone-specific alkaline phosphatase (BAP) and urinary pyridinoline (PYR) to creatinine (Cr) ratio (mmol PYR/micromol Cr). The mean 25(OH)D3 level was low (44 nmol/l; 68% < 50 nmol/l; range, 16-87) and was associated with self-reported sun exposure on winter weekends (r = 0.23, p = 0.01), school holidays (r = 0.22, p = 0.01), and weekdays (r = 0.17, p = 0.05). It was also associated with number of sports (r = 0.34, p < 0.001) and vigorous activity (r = 0.22, p = 0.01) but not television, computer, and video watching (r = -0.04, p = 0.68). In multivariate analysis, number of sports but not total sun exposure remained significantly associated with 25(OH)D3. Furthermore, 25(OH)D3 was significantly associated with BAP in cutpoint analysis (cutpoint 55 nmol/l, p = 0.03) but not continuous analysis (r = -0.12, p = 0.16) and PYR in both forms (r = -0.23, p = 0.01, cutpoint 43 nmol/l, p = 0.01). In conclusion, vitamin D insufficiency is common in healthy adolescent boys in winter in our setting, is primarily derived from sports-related sun exposure, and is associated with bone turnover markers. These data suggest that a 25(OH)D3 level of at least 43-55 nmol/l is required for optimal bone health in children.

Skeletal age deviation assessed by the Tanner-Whitehouse 2 method is associated with bone mass and fracture risk in children

The aim of this population-based case-control study was to describe the association among skeletal age deviation (SAD), bone density, and upper limb fracture risk in male and female children aged 9-16 years. A total of 321 fracture cases and 321 randomly selected individually matched controls were studied. Skeletal age was assessed by standard atlas. Bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry (DXA) and metacarpal index (MI). There were no significant differences in mean skeletal age or chronological age between fracture cases and controls. However, SAD was associated with total, hand, and female fracture risk (all P<0.05). The fracture associations became nonsignificant after adjustment for BMD and MI in all subgroups with the exception of hand fractures (OR, 0.67/year; 95% CI, 0.47-0.96). SAD was also positively associated with BMD at all sites (r=0.33-0.35, all P<0.05) and MI (r=0.20, P<0.05). The strength of association reduced but remained significant at most sites after adjustment for body size, maturity, age, and sex. In conclusion, SAD is positively associated with measures of bone strength and negatively associated with upper limb fracture risk (especially those of the hand) in children. SAD is simple to measure and gives additional information regarding bone health and fracture risk in children.

Soft drink and milk consumption, physical activity, bone mass, and upper limb fractures in children: a population-based case-control study

Carbonated beverages have been reported to increase fracture risk in children but the mechanism is unclear. The aim of this population-based case-control study was to investigate the association between soft drink and milk consumption, physical activity, bone mass, and upper limb fractures in children aged 9-16 years. A total of 206 fracture cases and 206 randomly selected individually matched controls were studied. There were 47 hand fractures; 128 wrist and forearm fractures, and 31 upper arm fractures. An interviewer-administered questionnaire was utilized to retrospectively assess last-year physical activity (including television, computer, and video watching) and to recall the average weekly consumption of milk, colas, and total carbonated drinks. Bone mass at the spine, hip, and total body was assessed by dual-energy X-ray absorptiometry (DXA) and metacarpal morphometry. For total fractures, none of the above drink types was significantly different between cases and controls. For wrist and forearm fractures, there was a positive association between cola drink consumption and fracture risk (OR 1.39/unit, 95% CI: 1.01, 1.91). Cola consumption was significantly correlated with television, computer, and video watching (r = 0.20, P = 0.001) but not bone mineral density or milk drinks. After adjustment for television, computer, and video watching and bone mineral density, the association between cola drinks and fracture risk became nonsignificant (OR 1.31/unit, 95% CI: 0.94, 1.83). No association with other fracture sites was observed. In conclusion, cola, but not total carbonated beverage consumption, is associated with increased wrist and forearm fracture risk in children. However, this association is not independent of other factors and appears to be mediated by television watching and bone mineral density but not by decreased milk intake.

Growth, children, and fractures

Fractures in childhood have long been considered an unavoidable consequence of growth. Studies in recent years have documented the epidemiology of these very common fractures and have also documented considerable variation by fracture type and from country to country. There have also been a number of studies aimed at identifying risk factors particularly for the most common distal forearm fracture. These studies have consistently associated bone mineral density with these fractures. Other possible risk factors include obesity, physical inactivity, sports, cola beverages, calcium intake, risk taking, and coordination. While prospective studies are required to confirm these risk factors, accumulating evidence now suggests that a substantial proportion of fractures in children are preventable.