Review of Fractures and Low Bone Mass in Children with Cerebral Palsy

Abstract

a b s t r a c tChildren with cerebral palsy have an increased risk of fracture and low bone mass. A systematic review was carried out to identify the associated or risk factors. The role of bone mineral density measurement (particularly whole-body or distal femur) by dual-energy X-ray absorptiometry and quantitative computed tomography is examined. Current strategies to prevent or treat the bone fragility in children with cerebral palsy are summarised. IntroductionCerebral palsy (CP) describes a group of permanent disorders of the development of movement and posture, causing activity limitation, that are attributed to non-progressive disturbances occurring in the developing fetal or infant brain. Its population-based prevalence has been reported as 1.2e3.6 per 1000 live births. 1 Among the physiological subtypes, spasticity is the most common (77e93%), followed by dyskinesias (2e15%) and ataxia (2e8%), isolated hypotonia (0.7e2.6%) being the least common physiological subtype. 1 Regarding the body part affected, total-body/ quadriplegic-type CP and diplegic-type CP are more common than hemiplegic-type.Cerebral palsy is one of the most common physical disabilities of childhood. The motor disorders of CP are often accompanied by disturbances of sensation, perception, cognition and communication, and by behaviour problems. In population-based surveys, the frequency of impairments is substantial, 70% of individuals showing mental retardation (IQ < 70) and 31e40% having ongoing epilepsy, 21e63% visual impairment and 11e13% hearing impairment. 1 Musculoskeletal problems include spasticity or other movement disorders, muscle and joint contractures, joint deformities, hip instability, scoliosis, gait disturbance and fractures. Fractures in children with cerebral palsyFractures are not uncommon in children with CP. In one series, 39% of children with quadriplegic CP gave a history of fracture. 2 The prevalence rate was 6% in 1637 patients with CP, 3 and 12% in another 763 children with CP. 4 A higher prevalence rate of 23% was reported in 88 children with quadriplegic CP. 5 The fracture incidence was estimated to be 4.8 per 100 personeyears among one study of 261 children with moderate-to-severe CP. 6 Thus, the fracture incidence in children with CP is much higher than that in the general paediatric population.The causes of fracture were not identified for 55% of individuals in one series. 3 These fractures occur with minimal trauma or are 'spontaneous' with no apparent history of injury. The diagnosis is thus delayed or even missed in those patients who cannot communicate. Even when there is clinical suspicion of a fracture, some low-energy metaphyseal fractures do not show up on plain radiography and can only be diagnosed with whole-body bone scanning. 7 Thus, bone fragility seems to be an underlying problem related to these 'spontaneous' fractures.One retrospective review identified 35 non-ambulatory children with quadriplegic spastic CP, all of Gross Motor Functional Classification System (GMFCS) level V, who had 57 '...

Bone Mineral Density in Adults With Cerebral Palsy

“…Several causes, including decreased ambulation, insufficient vitamin D or calcium, or anticonvulsants, supposedly induce low BMD in children and adolescents with CP (3). In addition, individuals with CP demonstrate a higher prevalence of fracture (4) and increased risk of fracture with minor stress (5). Fracture impedes ambulation and affects their quality of life (6).…”

Malnutrition and Associated Risk Factors Among Disabled Children. Special Considerations in the Pediatric Surgical “Fragile” Patients

“…These children have been known for osteopenia and low bone mineral density (28, 29) due in part to insufficient or no mobility at all, besides hypovitaminosis D, caused by hormonal factors, anticonvulsant therapy, low sun exposure, and poor nutrition (5, 25, 28). The fractures are either “spontaneous,” with no apparent history of injury, or occur with minimal trauma and are associated with a higher complication rate than fractures in healthy children (30). Preoperative mobilization and/or periods of immobilization due to surgery further exacerbate this problem (25, 27).…”