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Fractures in patients who have myelomeningocele
1Department of Orthopaedic Surgery, Children's Hospital of Michigan, Detroit.
Insights
Children with myelomeningocele experience fractures, particularly in the lower extremities, with incidence correlating to neurological involvement level. Most fractures occur before age nine and are often cast-related.
Area of Science:
- Orthopedics
- Pediatric Orthopedics
- Neurology
Background:
- Myelomeningocele is a complex congenital condition affecting neurological and musculoskeletal development.
- Fracture risk is a significant concern in children with myelomeningocele, impacting mobility and treatment.
- Understanding fracture patterns is crucial for effective management and prevention strategies.
Purpose of the Study:
- To investigate the incidence, characteristics, and influencing factors of fractures in children with myelomeningocele.
- To determine the relationship between the level of neurological involvement and fracture occurrence.
- To analyze fracture locations, age of onset, and potential contributing factors.
Main Methods:
- Retrospective review of medical records for 186 children diagnosed with myelomeningocele.
- Data collection on fracture incidence, location, age at fracture, and neurological level.
- Analysis of fracture characteristics, including association with casting and healing outcomes.
Main Results:
- 37% of children experienced 76 fractures, with incidence rising with higher neurological involvement (thoracic/upper lumbar).
- 86% of fractures occurred before age nine, 76% were cast-related, and 97% involved the lower extremity.
- Fractures were distal to neurological involvement, predominantly femur (thoracic) and tibia (lumbar). Metaphyseal/diaphyseal fractures healed well; physeal fractures led to complications like delayed union and growth arrest.
Conclusions:
- Fracture risk in myelomeningocele is directly linked to neurological deficit level and occurs predominantly in young children.
- Cast application is a significant risk factor for fractures, necessitating careful management.
- While metaphyseal and diaphyseal fractures generally heal well, physeal fractures pose a substantial risk for long-term limb deformities.
Abstract:
Thirty-seven (20 per cent) of 186 children who had myelomeningocele whose records were reviewed had sustained a total of seventy-six fractures. The frequency with which the fractures occurred was related directly to the level of neurological involvement. Thirteen (41 per cent) of the patients who had involvement at the thoracic level, fifteen (36 per cent) who had involvement at the upper lumbar level, eight (10 per cent) who had involvement at the lower lumbar level, and one (3 per cent) who had involvement at the sacral level sustained fractures. Sixty-five (86 per cent) of the fractures occurred before the child was nine years old, fifty-eight (76 per cent) were judged to be secondary to the limb being in a cast, and seventy-four (97 per cent) involved the lower extremity. Eleven patients, all of whom had thoracic or upper lumbar involvement, sustained fractures of multiple extremities. All fractures of the lower extremity were distal to the level of neurological involvement; they occurred predominantly in the femur in patients who had thoracic involvement and in the tibia in patients who had lumbar involvement. All of the metaphyseal and diaphyseal fractures healed satisfactorily, whether they were treated by immobilization in a plaster cast or in a bulky Webril dressing, although there were fewer complications in the latter group. The seven fractures that involved the physeal plate were a major problem, as three (43 per cent) had delayed union and two (29 per cent) developed premature growth arrest.