Distal forearm fractures increasing in children

Studies needed about possible contributing factors: activity patterns, amount of calcium intake.

Issue: November 2003

The incidence of childhood distal forearm fractures has risen significantly in boys and girls in the last 30 years, according to researchers at the Mayo Clinic in Rochester, Minn.

This news has clinicians and researchers wondering whether the increase is due to changes in activity patterns, dietary intake of calcium or both. Many argue that the report raises important questions and that more studies, especially prospective ones, are needed.

Researchers identified a higher age- and sex-adjusted incidence of distal forearm fractures in children and young adults from the Rochester area from 1999 to 2001 compared to 1969 to 1971 (372.9 vs. 263.3 fractures per 100,000). Incidence rates were actually higher from 1989 to 1991 than 1999 to 2001, 399.8 per 100,000, but they later leveled off.

Fracture incidence for boys and girls from 1969 to 1971 was compared with that for 1999 to 2001. After age adjustments, the incidence was 32% greater in boys and 56% greater in girls during the more recent time period, which was statistically significant. But, the rate of increase was not significantly different between boys and girls.

Boys fracture more often

Overall, boys had a higher fracture incidence. The number of fractures in girls peaked between ages 8 and 11, whereas it peaked between ages 11 and 14 in boys. These results are consistent with existing research, the investigators reported in the Journal of the American Medical Association.

Orthopedics Today spoke with members of the Pediatrics Section of its Editorial Advisory Board about the findings. Section Editor Laura L. Tosi, MD, described the results as a call-to-arms for better research into the development of peak bone mass.

“A critical issue that the authors address is that juices and soft drinks have replaced milk in children’s diets. It may be that children are not making strong bone because they’re not getting enough calcium.

“We may now be breeding a population of adults that’s going to do really poorly in old age because they failed to lay adequate bone mass to last a lifetime,” Tosi said in a phone interview. “This paper underscores a critical health issue.”

Vernon T. Tolo, MD, of Los Angeles, said, “Everything the study brings up — changes in activity patterns and reduced calcium intake — points to the appropriate villains.”

While skateboarding and in-line skating are a major source of wrist and distal radius fractures in California, Tolo said he would not want to discourage physical activity because it helps build bone mass. “Sports participants, however, should continue to be aware of safety features, such as wrist guards,” he said in a phone interview.

Calcium intake can be remedied by increased awareness by pediatricians. Girls who are not getting three to four glasses of milk daily should take calcium supplements, he said. “Probably the age for supplements needs to be moved to before age 11, since girls with the highest incidence of fractures were 8 to 11 years old.”

According to Dennis R. Wenger, MD, of Children’s Hospital of San Diego, “Our experience suggests that the change is due to a markedly different exposure to musculoskeletal stress in 2000 as compared to 1970. … A change in activity is the cause of the increased fracture incidence.”

For more information:

Khosla S, Melton LJ, Dekutoski MD, et al. Incidence of childhood distal forearm fractures over 30 years. JAMA. 2003;290:1479-1485.