Commentary and Perspective | February 01, 2012

Bone Mineral Density After Immobilization for Fractures in Adolescents: Commentary on an article by Dimitri Ceroni, MD, et al.: Effects of Cast-Mediated Immobilization on Bone Mineral Mass at arious !ites in Adolescents "it# $o"erE%tremity Fracture&
J. Eric Gordon, MD View Disclosures and Other Information The Journal of Bone & Joint Surgery. 2012; 9 !e19 1"2 doi!10#210$%&'&(#)#01**+

,lthou-h the adult ortho.aedic literature is re.lete with .a.ers addressin- the effects of fractures and conse/uent treatment on bone density and the .otential effect of low bone density in terms of refracture, little has been written about fractures in children and their effect on bone density# 0his .aucity of literature certainly is not related to a lac1 of reco-nition that refractures occur in the .ediatric .o.ulation; indeed, refracture followin- .ediatric forearm fractures has lon- been reco-ni2ed as a serious and common com.lication1,2# 3or is the .aucity of literature related to a lac1 of reco-nition that osteo.enia occurs followinfractures and subse/uent immobili2ation4# 5ather, the tools to be-in to /uantitati6ely understand these chan-es are only now be-innin- to be a..lied to the .ediatric .o.ulation# 0his .a.er by 7eroni et al# and a recent .a.er by Fun- et al# re.resent the be-innin-s of a real effort to understand the chan-es that occur in .ediatric bones as a result of immobili2ation followin- fracture# 7eroni et al# e8amined a .ros.ecti6e -rou. of adolescents followed durin- cast treatment for a distal tibial fracture# 0he in9ured limbs were com.ared with both the normal limb in the in9ured -rou. as well as with a control -rou. of healthy adolescents# 0he authors concluded that the bone mineral density of the in9ured limb was not si-nificantly different from that of the controls and thus the ori-inal fracture was unli1ely to be related to osteo.enia# Furthermore, the authors obser6ed a substantial decrease in bone mineral density and bone mineral content at multi.le sites throu-hout the affected limb at the time of cast remo6al, which may ha6e contributed to later refracture# It is of note that, althou-h multi.le measurements of bone density were obtained at the time of cast remo6al, no s.ecific measurements were .erformed at the fracture site itself# In their recent study, Fun- et al# e8amined the bone mineral density of the distal .art of the radius in children followin- distal radial fracture# 0hey com.ared the bone mineral density at the fracture site in the distal .art of the in6ol6ed radius with that in the distal .art of the unin6ol6ed radius without measurin- bone mineral density at distant sites# 0hey noted an increase in bone mineral density at the fracture site durincast immobili2ation with a continued increase in bone mineral density u. to twenty"four wee1s .ostin9ury and then a return to le6els com.arable with those in the distal .art of the unin6ol6ed radius at fifty"two wee1s# 7learly, a com.lete understandin- of the chan-es in bone mineral density and the mechanisms in6ol6ed followin- fractures eludes us at this time# :uestions remain as to whether there are differences between the

u..er and lower e8tremities; what mechanisms control bone density; and whether these mechanisms are mediated by the .resence of a fracture, immobili2ation, decreased wei-ht"bearin-, or some combination of these factors# In addition, both of these studies addressed only relati6ely sim.le fractures treated with cast immobili2ation# ;e do not 1now whether o.erati6ely treated fractures res.ond similarly or the e8act biolo-ical mechanisms by which this chan-e in bone mineral density is controlled# <ractically, understandinthese chan-es in a more /uantitati6e way could allow for a reduction in refractures in these children as well as im.ro6ed rehabilitation with more ra.id return to acti6ities# , fuller understandin- of the biolo-ical mechanisms could .otentially shed li-ht on a number of different .roblems associated with the de6elo.ment of osteo.enia after fractures and with .rolon-ed bed rest as well as osteo.orosis later in adulthood#

References
Introduction | References 1

'lount ;<; (chaefer ,,; &ohnson &=# Fractures of the forearm in children# &,>,# 19 2;120!111"$# [CrossRef]
2

(chwar2 3; <ienaar (; (chwar2 ,F; &elen >; (tyhler ;; >ayr &# 5efracture of the forearm in children# & 'one &oint (ur- 'r# 199$;+?!+ 0" #[Pu Med]
4

7onway F>; (tubenbord &@# 0he effects of immobili2ation on normal bone# & 'one &oint (ur- ,m# 194 ;1$!29?"402#

Fun- A'; =um.hrey >B; @ilden-orin @; @oldstein 3; =offin-er (,# 5a.id reminerali2ation of the distal radius after forearm fracture in children# & <ediatr Ortho.# 2011;41!14?" 4#[Pu Med][CrossRef]

http://jbjs.org/article.aspx?articleid=334927 Minerale densitii osoase Dup imobilizare a fracturilor la adolescenti: Comentariu la un articol de Dimitri Ceroni, MD, et al: "Efectele Magazin-mediate de imobilizare pe masa minerale osoase la diferite site-uri la adolescenti cu Inferioar-Extremitatea racture"! De"i literatura de specialitate ortopedice adult este plin cu lucrri care abordeaz efectele de fracturi "i de tratament ca urmare a densitii osoase "i efectul potenial de densitate osoas sczut #n termeni de refracture, putin a fost scris despre fracturi la copii "i efectul lor asupra densitatii osoase! $cest mic de literatur cu siguran nu este legat de lipsa de recunoa"tere a faptului c refractures apar #n populaia pediatric, #ntr-ade%r, refracture urmtoarele fracturi antebrat copii "i

adolesceni a fost mult timp recunoscut ca o complication& gra% "i comune, '! (ici nu este numarul mic de literatura de specialitate referitoare la lipsa de recunoa"tere, care apare #n urma osteopenie fracturi "i immobilization) ulterioare! Mai degrab, instrumentele pentru a #ncepe s #neleag cantitati% aceste modificri sunt abia acum #ncep s fie aplicate la populaia pediatric!$ceast lucrare de Ceroni et al! Ceroni et al! examinat un grup de adolesceni prospecti% urmat #n timpul tratamentului exprimate pentru o fractura de tibie distala! Membrele rnii au fost comparate at*t cu aspect normal #n grupul de rnii, precum "i cu un grup de control de adolesceni snto"i! $utorii au concluzionat ca densitatea minerala osoasa a membrelor %tmate nu a fost semnificati% diferit de cea a controalelor "i, astfel, fractura original a fost puin probabil s fie legate de osteopenie! Mai mult, autorii au obser%at o scdere substanial a densitii minerale osoase "i coninutul minerale osoase la site-uri multiple pe tot parcursul membrul afectat, la momentul scoaterii exprimate, care poate fi contribuit la refracture mai t*rziu! Este de reinut faptul c, de"i mai multe masuratori ale densitatii osoase au fost obinute la momentul #ndeprtrii exprimate, In studiul lor, recent, ung et al!+ examinat densitii minerale osoase #n partea distal a raza, #n copii dup fractura distala radiala! Ei au comparat densitii minerale osoase la locul fracturii, #n partea distal a raza implicat cu faptul c, #n partea distal a raza neimplicat fr msurarea densitii minerale osoase la site-uri distan! Ei au obser%at o cre"tere a densitii minerale osoase la locul fracturii #n timpul de imobilizare turnat cu o cre"tere continu a densitii minerale osoase p*n la douzeci "i patru sptm*ni postin,ur- "i apoi o re%enire la ni%eluri comparabile cu cele din partea distal a raza neafectat de la cincizeci dou sptm*ni! .n mod e%ident, o #nelegere complet a modificrilor densitii minerale osoase "i a mecanismelor implicate fracturi urmtoarele ne scap #n acest moment! .ntrebrile rm*n pentru a stabili dac exist diferene #ntre extremitile superioare "i inferioare, ceea ce mecanismelor de control densitatea osoasa, "i dac aceste mecanisme sunt mediate de prezena unei fracturi, imobilizare, scdere #n greutate-poart, sau o combinaie a acestor factori! .n plus, ambele din aceste studii adresate fracturi doar relati% simple, tratate cu imobilizare exprimate!(oi nu "tim dac fracturi operati% tratai raspunde in mod similar sau mecanismele exacte biologice prin care aceast sc/imbare a densitatii minerale osoase este controlat! 0ractic, intelegerea acestor modificri #ntr-un mod mai mult cantitati% ar putea permite o reducere #n

refractures, #n ace"ti copii, precum "i reabilitarea mai bun, cu re%enirea mai rapid la acti%itile!