title: Fracture after bisphosphonate treatment in children with cerebral palsy: the role of stress risers.
abstract: BACKGROUND
  In the nonambulatory cerebral palsy (CP) population with a prior history of fracture, the use of pamidronate is not always effective in preventing further fractures.
  
  
  OBJECTIVE
  To test the hypothesis that when fractures occur after cyclic pamidronate, they will be at the proximal or distal end of a pamidronate band.
  
  
  METHODS
  Retrospective review of our CP patient database revealed 53 children who had received one or more complete courses of pamidronate therapy (five cycles over 12 months). Medical records were screened to identify children who had sustained a fracture or fractures after completing treatment.
  
  
  RESULTS
  Of 53 patients treated with pamidronate, only 14 sustained fractures after treatment. Radiographs were available for 11 patients, showing 19 fractures. Sixty-three percent of these fractures were located at a junction with pamidronate bands but not within the bands.
  
  
  CONCLUSIONS
  We propose stress risers as the mechanism for fractures that have occurred where bone mineral density abruptly changes as a result of cyclic administration of pamidronate. We show a theoretical example of how alternative dosing might reduce the ratio and therefore decrease the chance of formation of a stress riser.
authors.affiliation: Alfred I. duPont Hospital for Children, P. O. Box 269, Wilmington, DE 19899, USA. tharcke@nemours.org
authors.forename: H Theodore
authors.initials: HT
authors.lastname: Harcke
authors.forename: Kimberly L
authors.initials: KL
authors.lastname: Stevenson
authors.forename: Heidi H
authors.initials: HH
authors.lastname: Kecskemethy
authors.forename: Steven J
authors.initials: SJ
authors.lastname: Bachrach
authors.forename: Leslie E
authors.initials: LE
authors.lastname: Grissom
mesh_terms: D000293:Adolescent; D050071:Bone Density Conservation Agents / Q000009:adverse effects / Q000627:therapeutic use; D002547:Cerebral Palsy / Q000150:complications* / Q000000981:diagnostic imaging / Q000188:drug therapy*; D002648:Child; D002675:Child, Preschool; D004164:Diphosphonates / Q000009:adverse effects* / Q000627:therapeutic use*; D005260:Female; D015775:Fractures, Stress / Q000139:chemically induced* / Q000000981:diagnostic imaging / Q000517:prevention & control*; D006801:Humans; D008297:Male; D000077268:Pamidronate; D011859:Radiography; D016896:Treatment Outcome
chemical_list: D050071:Bone Density Conservation Agents; D004164:Diphosphonates; D000077268:Pamidronate