Fractures of the Lower Limbs in Patients with Myelomeningocele
ALVIN A. FREEHAFER M.D. ROBERT H. ANSCHUETZ M.D. JOHN W. SHAFFER M.D. Introduction
Fractures occurring in the lower limbs of patients with myelomeningocele may present in unusual ways1,2,3,4,5,6,7. Because sensation is often absent or diminished, the presenting signs and symptoms are not pain as one usually expects. Prevention of fractures in this group of patients is important and can be achieved. Management of the fractures that occur in patients with neurological deficit differs from the management of fractures in patients with normal neurological function.
The purpose of this article is to redefine the problem of fractures in patients with myelomeningocele, discuss prevention, and describe management.
Materials and Methods
All fractures were reviewed from 1970 to 1980 except those previously reported by Drennan and Freehafer in 19711. The patients reviewed are among 145 seen at the Myelodysplasia Clinic at University Hospitals, and 38 seen at the Myelodysplasia Clinic at Cleveland Metropolitan General Hospital in Cleveland, Ohio. During this period 23 patients experienced 48 fractures.
All fractures occurred where neurological function was abnormal. They occurred throughout the femur and tibia, with a distribution similar to that reported in an earlier study2. Most occurred in the supracondylar region and the shaft of the femur.
Of the 48 fractures 20 were in patients who were immobilized in casts following surgery. Immobilization for three to four weeks was all the time necessary to cause enough disuse atrophy to predispose to fractures.
The incidence of fractures was variable. Our highest incidence was 16 per cent fractures per patient per year, although there were several years with no fractures recorded. The overall incidence for 1980 was 3 per cent. The authors believe that continued emphasis on weight-bearing, bracing, and caution should keep the incidence of fractures below the rate of 11.5 per cent reported by Quillis5.
The common signs and symptoms were a swollen lower limb, temperature elevation, and malaise. A clear history of a fracture occasionally occurred, but most patients sought medical advice more than several days following the fracture when swelling, fever, and malaise persisted. Frequently heat and redness at the fracture site suggested infection. A few patients became toxic and extremely ill after removal from hip spicas. Rapid heart rate, hypotension, lowered hematocrit, elevated white blood-cell count, and elevation of temperature were signs seen in a few patients, and these signs should raise suspicion of fracture. Placement of the child in the remaining "half shell" of the bivalved spica dramatically improved the toxic course in two patients. Orthoses as a means of immobilization have also been reported2.
Roentgenographic appearance of some of the fractures can be bizarre and may be mistaken for infection or tumor7. Callus formation is often exuberantl,3,7. Epiphyseal fractures often show marked widening of the growth plate with excessive callus5.
The principles of fracture care in patients with myelomeningocele were previously outlined by Drennan and Freehafer1. They continue to be useful. The authors feel that all myelodysplasia programs and clinics should develop guidelines that will reduce the incidence of fractures and their complications.
- Always inform parents, patients, and health personnel that fractures occur more readily because the bone is softer.
- Application and removal of braces and plaster casts must be done with great gentleness.
- Patients should be fitted with orthoses and allowed to stand as early as possible. This is at about 1 year of age in most patients.
- If spica casts are applied, patients should stand for meal times. Always use double spicas rather than single or one and one-half.
- Range of motion and stretching are potentially dangerous. Motion that occurs with sitting, lying, diaper changes, dressing, and bracing is sufficient.
- Skeletal or skin traction should be avoided.
- Open reductions are not necessary and are potentially dangerous.
- When children are removed from spica casts their joints are stiff and bones are soft, so precautions should be observed. These measures include early application of braces, standing, avoidance of stress on lower limbs in removal from plaster, and care in holding children in one's arms.
- Admit to the hospital children in plaster spicas when they are to be removed.
- Save the posterior half of a plaster spica when it is removed. If the child develops life-threatening derangements of vital functions, the patient can be managed in this shell for several days.
- Use soft splints and avoid hard splints.
- Apply orthoses as soon as possible and start weight-bearing with standing as soon as possible. In small children most fractures are clinically solid in one week, and in children over 10 by two weeks.
- One fracture may lead to another and to a whole series of fractures, especially if immobilization has been prolonged. In these instances every effort must be made to brace the children and have them stand in order to stimulate bone growth.
- The goal in treatment is to achieve a functional level after healing equal to that which existed before the fracture.
- Drennan, J. C, and A. A. Freehafer, Fractures of the lower extremities in paraplegic children. Clin Orthop, 77:211, 1971.
- Katz, J. F., Spontaneous fractures in paraplegic children. J Bone and Joint Surg, 35A:220, 1953.
- KorKonen, J., Fractures in myelodysplasia. Clin Orthop, 79:145, 1971.
- Michael, J. C. C, Fractures in lower limbs in spina bifida cystica-a survey of 44 fractures in 122 children. Dev Med Child Neurol, 12:88, 1970.
- Quillis, A., Fractures in children with myelomeningocele. Acta Orthop Scand, 45:883, 1974.
- Soutter, F. E., Spina bifida and epiphyseal displacement. J Bone and Joint Surg, 44-B:106, 1972.
- Townsend, P. F., H. H. Cowell, and N. L. Steg, Lower extremity fractures simulating infection in myelomeningocele. Clin Orthop, 144:255, 1979.