Assessment and management of the lower extremity in myelodysplasia

The goal in managing the lower extremity in a child with spina bifida is to achieve a pattern of development as near normal as possible. Lower limb deformities are produced by muscle imbalance, weight-bearing, and the postural effects of gravity. At any point in time, the management of the lower extremities will depend on the child's general development. Lower limb paralysis, hydrocephalus, bladder infections, hydromyelia, and Arnold Chiari malformation, all contribute to developmental delay. A child's potential for mobility varies with the severity of the motor and sensory deficit. Surgery is done to correct deformity, provide joint stability, and improve joint mobility. The results of surgery will be compromised if the child is not neurologically stable, or if appropriate therapy and orthotic care are not available. Muscle imbalance produces the problem of deformity and instability of the hip. Deformity must be corrected if the child is to assume an upright posture. Instability is of concern only in those children with a strong quadriceps muscle. Hip surgery for instability should be limited to one procedure, which must achieve a stable concentric reduction and balance the muscle forces about the hip. The common deformities seen at the knee are recurvatum, knee flexion contractures, and genu valgum. Most knee deformities can be corrected by soft tissue procedures. Well-designed orthoses rocker sole shoes, and appropriate gait training help prevent knee deformities. The goal in managing foot deformities is to achieve a plantigrade foot with stable skin. Whenever there is a problem with sensation, concentrated pressure in one area of a deformed foot will lead to skin breakdown. Surgical procedures must completely correct deformity and restore muscle imbalance. After surgery, meticulous orthotic care is required to prevent skin breakdown and avoid loss of correction. The orthopedist has a significant role in helping a child with spina bifida to achieve a pattern of development as near normal as possible. He or she must work in concert with a team of professionals and realize that orthopedic surgery is but an incident in the habilitative program. This rather chatty narrative is based on spina bifida care experience, in Sheffield, Toronto, and Chicago.