Toward the metaphysis and epiphysis, the cortex becomes thinner and the space is filled with thin calcified trabeculae known as trabecular or cancellous bone.
Eighty-ninety percent of the volume of cortical bone is calcified. The outer layer of the bone is comprised of a thick dense layer of calcified tissue known as cortical bone, which provides strength to the bone. This area becomes calcified and remodeled with bone when growth is complete. A layer of cartilage (growth plate) separates the epiphysis and metaphysis in growing bones. Each long bone is comprised of 2 wider ends (epiphyses), a tubular middle (diaphysis), and the developing zone between the 2 (metaphysis). The process of ossification of flat bones such as the skull, ileum, mandible, and scapula occurs through intramembranous ossification, whereas the long bones such as the tibia, femur, and humerus are formed through endochondral ossification. The skeleton of the developing embryo is primarily composed of either fibrous membranes or hyaline cartilage, which provide the medium for ossification. The Z-score is the number of standard deviations the patient’s BMD is more than or less than age-, sex-matched reference values.
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The current definition for osteoporosis in children includes a BMD Z-score less than −2.0 adjusted for age, gender, and body size plus a clinically significant history of fracture: (1) 2 upper extremity fractures, or (2) vertebral compression fracture, or (3) a single lower extremity fracture. The diagnosis of osteoporosis requires a clinically significant fracture history and low bone mineral content or bone mineral density (ISCD Pediatric Position Statement, 2008). Unlike adult osteoporosis, the consensus was that osteoporosis in children should not be determined based on densitometric criteria alone. The International Society of Clinical Densitometry released a position statement defining the parameters for the diagnosis of osteoporosis in children in 2008. However, over the past decade there have been advances in the diagnosis and diagnostic classifications for osteoporosis in children. The risk of fracture associated with low BMD, the evaluation of osteoporosis, and treatment options in children are less well defined. This article addresses the anatomy and structure of bone and bone metabolism, the clinical assessment of bone mass, the causes of osteoporosis and its evaluation and treatment in children with CP. Preventing or improving osteoporosis and maximizing bone accrual during critical stages of growth will minimize the future lifelong risks of fractures in children with CP. Bone density is significantly decreased, and children with CP often sustain painful fractures with minimal trauma that impair their function and quality of life. CP is the most prevalent childhood condition associated with osteoporosis. Osteoporosis evaluation and prevention is relevant to children with cerebral palsy (CP). Because the foundation for skeletal health is established so early in life, osteoporosis prevention begins by optimizing gains in bone mineral throughout childhood and adolescence. Accrual of bone mass occurs throughout childhood and early adulthood, and peak bone mass is a key determinant of the lifetime risk of osteoporosis. Despite advances in treating osteoporosis in the elderly, no cure exists. 1 Osteoporosis remains a major health problem worldwide, costing an estimated $13.8 billion in health care each year in the United States. Osteoporosis is a skeletal disorder characterized by compromised bone strength predisposing a person to an increased risk of fracture.
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