Peak bone mass (PBM) is defined as the amount of bony tissue present at the end of skeletal maturation [1]. Bone strength is mainly determined by volumetric density, i.e., the amount of bony tissue per unit of volume, by outer bone dimensions, by intraosseous microarchitecture, and by intrinsic bone quality [2]. The contribution of bone size to strength is illustrated by the recent observation that for matched vertebral height and volumetric density, patients with vertebral fracture have smaller crosssectional vertebral body area than nonfractured subjects [3]. Before puberty, no consistent gender difference in bone mass of axial or appendicular skeleton has been reported [4–6]. Furthermore, there is no evidence for a gender difference in bone mass at birth. Likewise, the volumetric bone mineral density (BMD) appears to be similar among female and male newborns [7]. This absence of gender difference in bone mass is maintained until the onset of pubertal maturation [8–10]. During puberty, bone mineral mass more than doubles in skeletal sites such as the lumbar spine [6,11]. This increase occurs approximately 2 years later in males than females. Then, a gender difference in bone mass is expressed. In addition to a possible late prepubertal increased value due to the 2-year delay in the onset of pubertal maturation in males, this difference appears to result essentially from a more prolonged bone growth period in males than females, with a larger increase in bone size and in cortical thickness [12]. During puberty, the accumulation rate in areal BMD at both the lumbar spine and femoral neck levels increases over a 3or 4year period in females and males, respectively [11]. The change in bone mass accumulation rate is less marked in the long bone diaphyses. Puberty affects bone size much more than volumetric BMD (Fig. 1). There is no significant gender difference in the volumetric trabecular density at the end of pubertal maturation [8,9,13,14]. However, blacks have greater volumetric density than whites [10,14]: trabecular number is similar, but the trabeculae appear to be thicker [15]. In cortical peripheral bone, there is no gender difference in the cross-sectional area of midfemoral shaft after adjustment for height and weight [13]. However, it is greater in blacks than whites for an identical cortical thickness [14]. Thus, despite the same cortical thickness, larger bones result in a greater bone mineral content. Bony tissue situated more distantly from the bone’s central axis confers a greater resistance to bending [2,16]. There is an asynchrony between the gain in statural height and bone mass growth [6,11,17]. Indeed, the peak of statural growth velocity precedes the peak of maximal bone mineral gain. In males, the greatest difference occurs in the 13–14 year age group and is more pronounced for lumbar spine and femoral neck than for midfemoral shaft [11]. In females, the largest difference occurs in the 11–12 year age group, corresponding in both genders to pubertal stages P2– P3. This phenomenon may be responsible for the occurrence of a transient relative increase in bone fragility that may account for the pattern of fracture Osteoporos Int (1999) Suppl. 2:S17–S23 s 1999 International Osteoporosis Foundation and National Osteoporosis Foundation Osteoporosis International
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