Skip to main content
SpringerLink
Log in

Diagnostic evaluation of bone densitometric size adjustment techniques in children with and without low trauma fractures

  • Original Article
  • Published:
Osteoporosis International Aims and scope Submit manuscript

Abstract

Summary

Several established methods are used to size adjust dual-energy X-ray absorptiometry (DXA) measurements in children. However, there is no consensus as to which method is most diagnostically accurate. All size-adjusted bone mineral density (BMD) values were more diagnostically accurate than non-size-adjusted values. The greatest odds ratio was estimated volumetric BMD for vertebral fracture.

Introduction

The size dependence of areal bone density (BMDa) complicates the use of DXA in children with abnormal stature. Despite several size adjustment techniques being proposed, there is no consensus as to the most appropriate size adjustment technique for estimating fracture risk in children. The aim of this study was to establish whether size adjustment techniques improve the diagnostic ability of DXA in a cohort of children with chronic diseases.

Methods

DXA measurements were performed on 450 children, 181 of whom had sustained at least one low trauma fracture. Lumbar spine (L2–L4) and total body less head (TBLH) Z-scores were calculated using different size adjustment techniques, namely BMDa and volumetric BMD for age (bone mineral apparent density (BMAD)); bone mineral content (BMC) and bone area for height; BMC for bone area; BMC for lean mass (adjusted for height); and BMC for bone and body size.

Results

Unadjusted L2–L4 and TBLH BMDa were most sensitive but least specific at distinguishing children with fracture. All size adjustments reduced sensitivity but increased post-test probabilities, from a pre-test probability of 40 % to between 58 and 77 %. The greatest odds ratio for fracture was L2–L4 BMAD for a vertebral fracture and TBLH for lean body mass (LBM) (adjusted for height) for a long bone fracture with diagnostic odds ratios of 9.3 (5.8–14.9) and 6.5 (4.1–10.2), respectively.

Conclusion

All size adjustment techniques improved the predictive ability of DXA. The most accurate method for assessing vertebral fracture was BMAD for age. The most accurate method for assessing long bone fracture was TBLH for LBM adjusted for height.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Leonard MB, Propert KJ, Zemel BS, Stallings VA, Feldman HI (1999) Discrepancies in pediatric bone mineral density reference data: potential for misdiagnosis of osteopenia. J Pediatr 135(2 Pt 1):182–188

    PubMed  CAS  Google Scholar 

  2. Fewtrell MS, British Paediatric & Adolescent Bone Group (2003) Bone densitometry in children assessed by dual X ray absorptiometry: uses and pitfalls. Arch Dis Child 88(9):795–798

    Article  PubMed  CAS  Google Scholar 

  3. Lewiecki EM, Gordon CM, Baim S, Leonard MB, Bishop NJ, Bianchi ML, Kalkwarf HJ, Langman CB, Plotkin H, Rauch F, Zemel BS, Binkley N, Bilezikian JP, Kendler DL, Hans DB, Silverman S (2008) International Society for Clinical Densitometry 2007 adult and pediatric official positions. Bone 43(6):1115–1121

    Article  PubMed  Google Scholar 

  4. Rüth EM, Weber LT, Schoenau E, Wunsch R, Seibel MJ, Feneberg R, Mehls O, Tönshoff B (2004) Analysis of the functional muscle-bone unit of the forearm in pediatric renal transplant recipients. Kidney Int 66(4):1694–1706

    Article  PubMed  Google Scholar 

  5. Leonard MB, Zemel BS (2002) Current concepts in pediatric bone disease. Pediatr Clin North Am 49(1):143–173

    Article  PubMed  Google Scholar 

  6. Gafni RI, Baron J (2004) Overdiagnosis of osteoporosis in children due to misinterpretation of dual-energy X-ray absorptiometry (DEXA). J Pediatr 144(2):253–257

    Article  PubMed  Google Scholar 

  7. Carter DR, Bouxsein ML, Marcus R (1992) New approaches for interpreting projected bone densitometry data. J Bone Miner Res 7(2):137–145

    Article  PubMed  CAS  Google Scholar 

  8. Kröger H, Kotaniemi A, Kröger L, Alhava E (1993) Development of bone mass and bone density of the spine and femoral neck—a prospective study of 65 children and adolescents. Bone Miner 23(3):171–182

    Article  PubMed  Google Scholar 

  9. Mølgaard C, Thomsen BL, Prentice A, Cole TJ, Michaelsen KF (1997) Whole body bone mineral content in healthy children and adolescents. Arch Dis Child 76(1):9–15

    Article  PubMed  Google Scholar 

  10. Warner JT, Cowan FJ, Dunstan FD, Evans WD, Webb DK, Gregory JW (1998) Measured and predicted bone mineral content in healthy boys and girls aged 6–18 years: adjustment for body size and puberty. Acta Paediatr 87(3):244–249

    Article  PubMed  CAS  Google Scholar 

  11. Ellis KJ, Shypailo RJ, Hardin DS, Perez MD, Motil KJ, Wong WW, Abrams SA (2001) Z score prediction model for assessment of bone mineral content in pediatric diseases. J Bone Miner Res 16(9):1658–1664

    Article  PubMed  CAS  Google Scholar 

  12. Schoenau E, Neu CM, Rauch F, Manz F (2002) Gender-specific pubertal changes in volumetric cortical bone mineral density at the proximal radius. Bone 31(1):110–113

    Article  PubMed  CAS  Google Scholar 

  13. Horlick M, Wang J, Pierson RN Jr, Thornton JC (2004) Prediction models for evaluation of total-body bone mass with dual-energy X-ray absorptiometry among children and adolescents. Pediatrics 114(3):e337–e345

    Article  PubMed  Google Scholar 

  14. Högler W, Briody J, Woodhead HJ, Chan A, Cowell CT (2003) Importance of lean mass in the interpretation of total body densitometry in children and adolescents. J Pediatr 143(1):81–88

    Article  PubMed  Google Scholar 

  15. Crabtree NJ, Kibirige MS, Fordham JN, Banks LM, Muntoni F, Chinn D, Boivin CM, Shaw NJ (2004) The relationship between lean body mass and bone mineral content in paediatric health and disease. Bone 35(4):965–972

    Article  PubMed  CAS  Google Scholar 

  16. Leonard MB, Shults J, Elliott DM, Stallings VA, Zemel BS (2004) Interpretation of whole body dual energy X-ray absorptiometry measures in children: comparison with peripheral quantitative computed tomography. Bone 34(6):1044–1052

    Article  PubMed  Google Scholar 

  17. National Osteoporosis Society (2004) A practical guide to bone densitometry in children. National Osteoporosis Society, Bath

    Google Scholar 

  18. Duke PM, Litt IF, Gross RT (1980) Adolescents' self-assessment of sexual maturation. Pediatrics 66(6):918–920

    PubMed  CAS  Google Scholar 

  19. Crabtree NJ (2007) Interpretation of paediatric bone evaluation by dual energy X-ray absorptiometry (DXA). University of Birmingham, Birmingham

    Google Scholar 

  20. Lu PW, Cowell CT, LLoyd-Jones SA, Briody JN, Howman-Giles R (1996) Volumetric bone mineral density in normal subjects, aged 5–27 years. J Clin Endocrinol Metab 81(4):1586–1590

    Article  PubMed  CAS  Google Scholar 

  21. Goulding A, Jones IE, Taylor RW, Manning PJ, Williams SM (2000) More broken bones: a 4-year double cohort study of young girls with and without distal forearm fractures. J Bone Miner Res 15(10):2011–2018

    Article  PubMed  CAS  Google Scholar 

  22. Goulding A, Jones IE, Taylor RW, Williams SM, Manning PJ (2001) Bone mineral density and body composition in boys with distal forearm fractures: a dual-energy X-ray absorptiometry study. J Pediatr 139(4):509–515

    Article  PubMed  CAS  Google Scholar 

  23. Frost HM (1987) The mechanostat: a proposed pathogenic mechanism of osteoporoses and the bone mass effects of mechanical and nonmechanical agents. Bone Miner 2(2):73–85

    PubMed  CAS  Google Scholar 

  24. Schoenau E, Neu CM, Beck B, Manz F, Rauch F (2002) Bone mineral content per muscle cross-sectional area as an index of the functional muscle-bone unit. J Bone Miner Res 17(6):1095–1101

    Article  PubMed  Google Scholar 

  25. Fewtrell MS, Gordon I, Biassoni L, Cole TJ (2005) Dual X-ray absorptiometry (DXA) of the lumbar spine in a clinical paediatric setting: does the method of size-adjustment matter? Bone 37(3):413–419

    Article  PubMed  CAS  Google Scholar 

  26. Prentice A, Parsons TJ, Cole TJ (1994) Uncritical use of bone mineral density in absorptiometry may lead to size-related artifacts in the identification of bone mineral determinants. Am J Clin Nutr 60(6):837–842

    PubMed  CAS  Google Scholar 

  27. Kanis JA, Johnell O, De Laet C, Johansson H, Oden A, Delmas P, Eisman J, Fujiwara S, Garnero P, Kroger H, McCloskey EV, Mellstrom D, Melton LJ, Pols H, Reeve J, Silman A, Tenenhouse A (2004) A meta-analysis of previous fracture and subsequent fracture risk. Bone 35(2):375–382

    Article  PubMed  CAS  Google Scholar 

  28. Goulding A, Jones IE, Williams SM, Grant AM, Taylor RW, Manning PJ, Langley J (2005) First fracture is associated with increased risk of new fractures during growth. J Pediatr 146(2):286–288

    Article  PubMed  Google Scholar 

  29. Warriner AH, Patkar NM, Yun H, Delzell E (2011) Minor, major, low-trauma, and high-trauma fractures: what are the subsequent fracture risks and how do they vary? Curr Osteoporos Rep 9(3):122–128

    Article  PubMed  Google Scholar 

  30. Clark EM, Ness AR, Tobias JH (2008) Vigorous physical activity increases fracture risk in children irrespective of bone mass: a prospective study of the independent risk factors for fractures in healthy children. J Bone Miner Res 23(7):1012–1022

    Article  PubMed  Google Scholar 

  31. Jones G, Ma D, Cameron F (2006) Bone density interpretation and relevance in Caucasian children aged 9–17 years of age: insights from a population-based fracture study. J Clin Dens 9(2):202–209

    Article  Google Scholar 

  32. Clark EM, Tobias JH, Ness AR (2006) Association between bone density and fractures in children: a systematic review and meta-analysis. Pediatrics 117(2):e291–e297

    Article  PubMed  CAS  Google Scholar 

  33. Skaggs DL, Loro ML, Pitukcheewanont P, Tolo V, Gilsanz V (2001) Increased body weight and decreased radial cross-sectional dimensions in girls with forearm fractures. J Bone Miner Res 16(7):1337–1342

    Article  PubMed  CAS  Google Scholar 

  34. Clark EM, Ness AR, Bishop NJ, Tobias JH (2006) Association between bone mass and fractures in children: a prospective cohort study. J Bone Miner Res 21(9):1489–1495

    Article  PubMed  Google Scholar 

  35. Manias K, McCabe D, Bishop N (2006) Fractures and recurrent fractures in children; varying effects of environmental factors as well as bone size and mass. Bone 39(3):652–657

    Article  PubMed  Google Scholar 

  36. Seeman E (2003) Invited review: pathogenesis of osteoporosis. J Appl Physiol 95(5):2142–2151

    PubMed  Google Scholar 

Download references

Conflicts of interest

None.

Author information

Authors and Affiliations

  1. Department of Nuclear Medicine, Queen Elizabeth Hospital, Birmingham, UK

    N. J. Crabtree

  2. Department of Endocrinology, Birmingham Children’s Hospital NHS Foundation Trust, Steelhouse Lane, Birmingham, B4 6NH, UK

    N. J. Crabtree, W. Högler & N. J. Shaw

  3. Department of Endocrinology, University of Birmingham, Birmingham, UK

    M. S. Cooper

Authors
  1. N. J. Crabtree
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. W. Högler
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. M. S. Cooper
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. N. J. Shaw
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to N. J. Crabtree.

Electronic supplementary material

Below is the link to the electronic supplementary material.

ESM 1

(DOC 106 kb)

Rights and permissions

Reprints and permissions

About this article

Cite this article

Crabtree, N.J., Högler, W., Cooper, M.S. et al. Diagnostic evaluation of bone densitometric size adjustment techniques in children with and without low trauma fractures. Osteoporos Int 24, 2015–2024 (2013). https://doi.org/10.1007/s00198-012-2263-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00198-012-2263-8

Keywords

Search

Navigation