Skip to main content
SpringerLink
Log in

Childhood Obesity Is Associated With Increased Risk of Most Lower Extremity Fractures

  • Symposium: Childhood Obesity and Musculoskeletal Problems
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

A number of studies have found an increased risk of lower extremity injuries in obese patients. Most studies, however, are unable to provide stable population-based estimates based on the degree of obesity and few assess the risk pertaining to more detailed fracture location in the lower extremities.

Questions/purposes

We therefore investigated the relationship between obesity and lower extremity fractures in different age and fracture locations in a stable population.

Methods

This is a population-based, cross-sectional study from the electronic medical records of 913,178 patients aged 2 to 19 years. The body mass index (BMI) for each patient in the cohort was used to stratify patients into five weight classes (underweight, normal weight, overweight, moderate obesity, and extreme obesity) based on BMI for age. Records were assessed for the occurrence of lower extremity fractures for each cohort member. The associations among the five weight classes and specific lower extremity fractures were estimated using multiple logistic regression models and expressed with odds ratios (ORs) and 95% confidence intervals (CIs) using multivariate analysis to adjust for patient demographic variables.

Results

Overweight, moderately obese, and extremely obese patients all had an increased OR of fractures of the foot (OR, 1.14, 1.23, and 1.42, respectively, with 95% CI, 1.04–1.24, 1.12–1.35, and 1.26–1.61, respectively) along with the ankle, knee, and leg (OR, 1.27, 1.28, and 1.51, respectively, with 95% CI, 1.16–1.39, 1.15–1.42, and 1.33–1.72, respectively). The association was strongest in the 6- to 11-year-old age group. We found no association between increasing BMI and increased risk of fractures of the femur and hip.

Conclusions

Increasing BMI is associated with increased odds of foot, ankle, leg, and knee fractures in children.

Level of Evidence

Level III, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Adams AL, Kessler JI, Deramerian K, Smith N, Black MH, Porter AH, Jacobsen SJ, Koebnick C. Associations between childhood obesity and upper and lower extremity injuries. Inj Prev. 2012 Jul 11 [Epub ahead of print].

  2. Bazelmans C, Coppieters Y, Godin I, Parent F, Berghmans L, Dramaix M, Levêque A. Is obesity associated with injuries among young people? Eur J Epidemiol. 2004;19:1037–1042.

    Article  PubMed  CAS  Google Scholar 

  3. Chan G, Chen CT. Musculoskeletal effects of obesity. Curr Opin Pediatr. 2009;21:65–70.

    Article  PubMed  Google Scholar 

  4. Chen W, Petitti DB, Enger S. Limitations and potential uses of census-based data on ethnicity in a diverse community. Ann Epidemiol. 2004;14:339–345.

    Article  PubMed  Google Scholar 

  5. Cheng JC, Shen WY. Limb fracture pattern in different pediatric age groups: a study of 3,350 children. J Orthop Trauma. 1993;7:15–22.

    Article  PubMed  CAS  Google Scholar 

  6. De Schepper J, Van den Broeck M, Jonckheer MH. Study of lumbar spine bone mineral density in obese children. Acta Paediatr. 1995;84:313–315.

    Article  PubMed  Google Scholar 

  7. Fischer S, Milinarsky A, Giadrosich V, Dib G, Arriagada M, Arinoviche R. X-ray absorptiometry of bone in obese and eutrophic children from Valparaiso, Chile. J Rheumatol. 2000;27:1294–1296.

    CAS  Google Scholar 

  8. Flegal KM, Wei R, Ogden CL, Freedman DS, Johnson CL, Curtin LR. Characterizing extreme values of body mass index-for-age by using the 2000 Centers for Disease Control and Prevention growth charts. Am J Clin Nutr. 2009;90:1314–1320.

    Article  PubMed  CAS  Google Scholar 

  9. Gao Y. Children hospitalized with lower extremity fractures in the United States in 2006: a population-based approach. Iowa Orthop J. 2011;31:173–180.

    PubMed  Google Scholar 

  10. Gordon-Larsen P, Adair LS, Popkin BM. The relationship of ethnicity, socioeconomic factors, and overweight in US adolescents. Obes Res. 2003;11:121–129.

    Article  PubMed  Google Scholar 

  11. Goulding A, Taylor RW, Jones IE, Manning PJ, Williams SM. Spinal overload: a concern for obese children and adolescents? Osteoporos Int. 2002;13:835–840.

    Article  PubMed  CAS  Google Scholar 

  12. Goulding A, Taylor RW, Jones IE, McAuley KA, Manning PJ, Williams SM. Overweight and obese children have low bone mass and area for their weight. Int J Obes Relat Metab Disord. 2000;24:627–632.

    Article  PubMed  CAS  Google Scholar 

  13. Haerens L, Deforche B, Maes L, Cardon G, De Bourdeaudhuij I. Physical activity and endurance in normal weight versus overweight boys and girls. J Sports Med Phys Fitness. 2007;47:344–350.

    PubMed  CAS  Google Scholar 

  14. Haricharan RN, Griffin RL, Barnhart DC, Harmon CM, McGwin G. Injury patterns among obese children involved in motor vehicle collisions. J Pediatr Surg. 2009;44:1218–1222; discussion 1222.

    Google Scholar 

  15. Hasanoglu A, Bideci A, Cinaz P, Tumer L, Unal S. Bone mineral density in childhood obesity. J Pediatr Endocrinol Metab. 2000;13:307–311.

    Article  PubMed  CAS  Google Scholar 

  16. Kato I, Toniolo P, Zeleniuch-Jacquotte A, Shore RE, Koenig KL, Akhmedkhanov A, Riboli E. Diet, smoking and anthropometric indices and postmenopausal bone fractures: a prospective study. Int J Epidemiol. 2000;29:85–92.

    Article  PubMed  CAS  Google Scholar 

  17. Koebnick C, Getahun D, Smith N, Porter AH, Der-Sarkissian JK, Jacobsen SJ. Extreme childhood obesity is associated with increased risk for gastroesophageal reflux disease in a large population-based study. Int J Pediatr Obes. 2011;6:e257–e263.

    Article  PubMed  Google Scholar 

  18. Krieger N, Chen JT, Waterman PD, Rehkopf DH, Subramanian SV. Painting a truer picture of US socioeconomic and racial/ethnic health inequalities: the Public Health Disparities Geocoding Project. Am J Public Health. 2005;95:312–323.

    Article  PubMed  Google Scholar 

  19. Krieger N, Waterman P, Lemieux K, Zierler S, Hogan JW. On the wrong side of the tracts? Evaluating the accuracy of geocoding in public health research. Am J Public Health. 2001;91:1114–1116.

    Article  PubMed  CAS  Google Scholar 

  20. Kuczmarski RJ, Ogden CL, Guo SS, Grummer-Strawn LM, Flegal KM, Mei Z, Wei R, Curtin LR, Roche AF, Johnson CL. 2000 CDC growth charts for the United States: methods and development. Vital Health Stat 11. 2002;246:1–190.

    Google Scholar 

  21. Landin LA. Fracture patterns in children. Analysis of 8,682 fractures with special reference to incidence, etiology and secular changes in a Swedish urban population 1950-1979. Acta Orthop Scand Suppl. 1983;202:1–109.

    PubMed  CAS  Google Scholar 

  22. Landin LA. Epidemiology of children’s fractures. J Pediatr Orthop B. 1997;6:79–83.

    Article  PubMed  CAS  Google Scholar 

  23. Lauritzen JB. Hip fractures. Epidemiology, risk factors, falls, energy absorption, hip protectors, and prevention. Dan Med Bull. 1997;44:155–168.

    PubMed  CAS  Google Scholar 

  24. Leonard MB, Shults J, Wilson BA, Tershakovec AM, Zemel BS. Obesity during childhood and adolescence augments bone mass and bone dimensions. Am J Clin Nutr. 2004;80:514–523.

    PubMed  CAS  Google Scholar 

  25. Manzoni P, Brambilla P, Pietrobelli A, Beccaria L, Bianchessi A, Mora S, Chiumello G. Influence of body composition on bone mineral content in children and adolescents. Am J Clin Nutr. 1996;64:603–607.

    PubMed  CAS  Google Scholar 

  26. Matter KC, Sinclair SA, Hostetler SG, Xiang H. A comparison of the characteristics of injuries between obese and non-obese inpatients. Obesity (Silver Spring). 2007;15:2384–2390.

    Article  Google Scholar 

  27. McHugh MP. Oversized young athletes: a weighty concern. Br J Sports Med. 2010;44:45–49.

    Article  PubMed  CAS  Google Scholar 

  28. Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States, 1999-2004. JAMA. 2006;295:1549–1555.

    Article  PubMed  CAS  Google Scholar 

  29. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity and trends in body mass index among US children and adolescents, 1999-2010. JAMA. 2012;307:483–490.

    Article  PubMed  Google Scholar 

  30. Pollack KM, Xie D, Arbogast KB, Durbin DR. Body mass index and injury risk among US children 9-15 years old in motor vehicle crashes. Inj Prev. 2008;14:366–371.

    Article  PubMed  CAS  Google Scholar 

  31. Pomerantz WJ, Timm NL, Gittelman MA. Injury patterns in obese versus nonobese children presenting to a pediatric emergency department. Pediatrics. 2010;125:681–685.

    Article  PubMed  Google Scholar 

  32. Rana AR, Michalsky MP, Teich S, Groner JI, Caniano DA, Schuster DP. Childhood obesity: a risk factor for injuries observed at a level-1 trauma center. J Pediatr Surg. 2009;44:1601–1605.

    Article  PubMed  Google Scholar 

  33. Riddiford-Harland DL, Steele JR, Baur LA. Upper and lower limb functionality: are these compromised in obese children? Int J Pediatr Obes. 2006;1:42–49.

    Article  PubMed  Google Scholar 

  34. Smith N, Coleman KJ, Lawrence JM, Quinn VP, Getahun D, Reynolds K, Chen W, Porter AH, Jacobsen SJ, Koebnick C. Body weight and height data in electronic medical records of children. Int J Pediatr Obes. 2010;5:237–242.

    Article  PubMed  Google Scholar 

  35. Strauss RS, Pollack HA. Epidemic increase in childhood overweight, 1986-1998. JAMA. 2001;286:2845–2848.

    Article  PubMed  CAS  Google Scholar 

  36. Taylor ED, Theim KR, Mirch MC, Ghorbani S, Tanofsky-Kraff M, Adler-Wailes DC, Brady S, Reynolds JC, Calis KA, Yanovski JA. Orthopedic complications of overweight in children and adolescents. Pediatrics. 2006;117:2167–2174.

    Article  PubMed  Google Scholar 

  37. Wang Y, Beydoun MA. The obesity epidemic in the United States—gender, age, socioeconomic, racial/ethnic, and geographic characteristics: a systematic review and meta-regression analysis. Epidemiol Rev. 2007;29:6–28.

    Article  PubMed  CAS  Google Scholar 

  38. Wang Y, Zhang Q. Are American children and adolescents of low socioeconomic status at increased risk of obesity? Changes in the association between overweight and family income between 1971 and 2002. Am J Clin Nutr. 2006;84:707–716.

    PubMed  CAS  Google Scholar 

  39. Wilder RP, Cicchetti M. Common injuries in athletes with obesity and diabetes. Clin Sports Med. 2009;28:441–453.

    Article  PubMed  Google Scholar 

  40. Worlock P, Stower M. Fracture patterns in Nottingham children. J Pediatr Orthop. 1986;6:656–660.

    Article  PubMed  CAS  Google Scholar 

  41. Zonfrillo MR, Seiden JA, House EM, Shapiro ED, Dubrow R, Baker MD, Spiro DM. The association of overweight and ankle injuries in children. Ambul Pediatr. 2008;8:66–69.

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

We thank Hooman Nikizad for preparation of references and Gez Bowman for help with table preparation.

Author information

Authors and Affiliations

  1. Kaiser Los Angeles Medical Center, 4760 Sunset Boulevard, Los Angeles, CA, 90027, USA

    Jeff Kessler MD, Corinna Koebnick PhD, MPH, Ning Smith PhD & Annette Adams PhD, MPH

  2. Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA

    Jeff Kessler MD, Corinna Koebnick PhD, MPH, Ning Smith PhD & Annette Adams PhD, MPH

Authors
  1. Jeff Kessler MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Corinna Koebnick PhD, MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Ning Smith PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Annette Adams PhD, MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Jeff Kessler MD.

Additional information

Each author certifies that he or she, or a member of his or her immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.

Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.

About this article

Cite this article

Kessler, J., Koebnick, C., Smith, N. et al. Childhood Obesity Is Associated With Increased Risk of Most Lower Extremity Fractures. Clin Orthop Relat Res 471, 1199–1207 (2013). https://doi.org/10.1007/s11999-012-2621-z

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11999-012-2621-z

Keywords

Search

Navigation