Bone Density Interpretation and Relevance in Caucasian Children Aged 9-17 Years of Age: Insights from a Population-based Fracture Study

The interpretation of bone density measurement in children is difficult due to a number of factors including rapid change in body size and uncertain clinical significance of bone density in children. This study asked two questions. (1) Is there a preferred bone density measurement site or type for fracture risk in children? (2) What is the best way to interpret bone density in children? This population-based case control study included 321 upper limb fracture cases and 321 class- and sex- matched randomly selected controls. Bone density at the hip, spine, and total body (including the arm) was measured by a Hologic QDR2000 densitometer (Waltham, MA) and examined as bone area (BA), bone mineral content (BMC), bone mineral density (BMD), bone mineral apparent density (BMAD), and BMC/lean mass (BMCLM). The only dual-energy X-ray absorptiometry (DXA) variables that were consistently associated with fracture risk in both boys and girls were spine BMD and BMAD for total upper limb fractures, and spine and hip BMAD for wrist and forearm fractures. No significant associations were observed for BA and BMCLM and inconsistent associations for BMC and other BMD sites. Five-yr fracture risk varied from 15-24% depending on site and gender in a child with a Z-score of -3. In the controls, all DXA variables were associated with age, height, and weight, but the weakest associations were with BMAD. In conclusion, in this study the spine BMAD had the strongest and most consistent association with upper limb fracture risk in children. The associations with age and body size imply that age specific Z-scores will be the most convenient for interpretation of DXA measures in children. Five-yr wrist and forearm fracture risk has potential as a clinical endpoint of immediate relevance.