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Fractures in Children With Cerebral Palsy: A Systematic Review
Laura A Bentley1,2, Maddison J Taylor1,2, Denise S K Brookes1,2
1Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia.
Insights
Children with cerebral palsy (CP) functioning at Gross Motor Function Classification System (GMFCS) levels III-V experience fragility fractures, primarily in the lower extremities. Modifiable risk factors include poor nutrition, weight imbalance, seizures, and limited weight-bearing activity.
Area of Science:
- Pediatric Orthopedics
- Neurology
- Rehabilitation Medicine
Background:
- Children with cerebral palsy (CP) classified under Gross Motor Function Classification System (GMFCS) levels III-V are at increased risk for reduced bone strength and low-trauma fractures.
- Understanding fracture patterns and risk factors is crucial for this vulnerable population.
Purpose of the Study:
- To systematically review and identify fracture rates, common locations, and associated risk factors in children with CP (GMFCS III-V).
Main Methods:
- A systematic literature search was conducted across five major databases (MEDLINE, Embase, CINAHL, Web of Science, PsycINFO) up to November 2024.
- Studies involving children under 18 with CP (GMFCS III-V) and reporting baseline fracture data were included, with methodological quality assessed using the Newcastle Ottawa Scale.
Main Results:
- Thirty studies were included, revealing fracture rates from 2.2 to 4.8 per 100 child-years and a lifetime prevalence of 9.4% to 15.5%.
- Lower extremity fractures, particularly of the femur (54.1%), were most common. High-quality evidence identified low bone mineral density, epilepsy, and weight imbalance as key risk factors.
Conclusions:
- Children with CP (GMFCS III-V) are susceptible to fragility fractures in the lower extremities.
- Identified modifiable risk factors include poor nutrition, weight imbalance, uncontrolled seizures, and insufficient weight-bearing activity.
- Variability in study quality and reporting necessitates cautious interpretation of findings.
Context:
Children with cerebral palsy (CP) functioning at Gross Motor Function Classification System (GMFCS) level III-V are at risk of reduced bone strength and low-trauma fractures.
Objective:
This systematic literature review aimed to identify fracture rates, locations, and risk factors in this population.
Data Sources:
Five databases (MEDLINE, Embase, CINAHL, Web of Science, and PsycINFO) were searched up until November 2024.
Study Selection:
Studies were included if they involved children younger than 18 years with CP (GMFCS III-V). Included study designs were cross-sectional, cohort, case-control, or experimental, including both randomized control trials and quasi-experimental, which reported baseline data separately. The Newcastle Ottawa Scale was used to assess methodological quality.
Data Extraction:
Study characteristics, population characteristics, fracture rate, location, and risk factors identified were extracted.
Results:
Out of 2220 studies, 30 were included. The fracture rate ranged from 2.2 to 4.8 per 100 child-years, and lifetime prevalence estimates were between 9.4% and 15.5%. The most frequently reported fracture location was in the lower extremities, particularly the femur (54.1%). Risk factors for fracture supported by high-quality evidence were low bone mineral density, epilepsy, and weight imbalance; factors with mixed-quality evidence were anticonvulsant use, feeding difficulties, reduced weight bearing, history of fracture, and increasing age.
Limitations:
Variability in methodological quality across studies and inconsistent reporting limited the generalizability of findings.
Conclusions:
Children with CP functioning at GMFCS III-V are prone to fragility fractures in the lower extremities with several modifiable risk factors identified, including poor nutrition, weight imbalance, uncontrolled seizures, and limited weight-bearing activity.
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