Osteoporosis in Pediatric Orthopaedics: Congenital Diseases, Medical Management, and Perioperative Considerations

Abstract Purpose of Review Pediatric osteoporosis is a heterogeneous group of primary and secondary disorders that creates challenges for orthopaedic surgeons. This review summarizes evidence on conditions commonly encountered in pediatric orthopedic practice, medical management strategies, and perioperative care for children with bone fragility. Recent Findings Diagnostic approaches have been evolving toward integrating fracture characteristics, skeletal risk factors, and bone mineral density (BMD). A single low-trauma vertebral compression fracture is now sufficient for diagnosis of osteoporosis in children regardless of BMD. Intravenous bisphosphonates remain first-line therapy, with recent meta-analyses confirming consistent BMD gains and, observationally, a reduction in fracture risk. Bisphosphonates are generally given to children who have sustained low-trauma vertebral fractures and considered for other children with recurrent long bone fractures with low BMD. Early intervention with bisphosphonates may also be warranted for children with high-risk diseases, such as Duchenne’s Muscular Dystrophy (DMD). Biologic agents are emerging in clinical trials and select specialized use, but further research is needed to understand their role in pediatric osteoporosis. Denosumab carries a substantial risk for rebound hypercalcemia in children with osteogenesis imperfecta (OI), limiting its use to selected indications. Preliminary reporting from a large trial of anti-sclerostin therapy in children with osteogenesis imperfecta suggests significant BMD increases while fracture-reduction endpoints were not met, underscoring the limitations of BMD as a surrogate in pediatric bone fragility trials. Summary Providing optimal care for this unique group of patients requires multidisciplinary coordination amongst orthopaedic surgeons, endocrinologists, geneticists, and rehabilitation specialists. Evidence-based management includes preoperative bone health evaluation, procedure-specific modifications in fragile bone, nutritional optimization, and coordinated bisphosphonate timing.