Fractures in Children With Cerebral Palsy: A Systematic Review.

Abstract

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. This systematic literature review aimed to identify fracture rates, locations, and risk factors in this population. Five databases (MEDLINE, Embase, CINAHL, Web of Science, and PsycINFO) were searched up until November 2024. 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. Study characteristics, population characteristics, fracture rate, location, and risk factors identified were extracted. 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. Variability in methodological quality across studies and inconsistent reporting limited the generalizability of findings. 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.