Fractures in myelomeningocele

Abstract

BackgroundIn patients with myelomeningocele (MMC), a high number of fractures occur in the paralyzed extremities, affecting mobility and independence. The aims of this retrospective cross-sectional study are to determine the frequency of fractures in our patient cohort and to identify trends and risk factors relevant for such fractures.Materials and methodsBetween March 1988 and June 2005, 862 patients with MMC were treated at our hospital. The medical records, surgery reports, and X-rays from these patients were evaluated.ResultsDuring the study period, 11% of the patients (n = 92) suffered one or more fractures. Risk analysis showed that patients with MMC and thoracic-level paralysis had a sixfold higher risk of fracture compared with those with sacral-level paralysis. Femoral-neck z-scores measured by dual-energy X-ray absorptiometry (DEXA) differed significantly according to the level of neurological impairment, with lower z-scores in children with a higher level of lesion. Furthermore, the rate of epiphyseal separation increased noticeably after cast immobilization. Mainly patients who could walk relatively well were affected.ConclusionsPatients with thoracic-level paralysis represent a group with high fracture risk. According to these results, fracture and epiphyseal injury in patients with MMC should be treated by plaster immobilization. The duration of immobilization should be kept to a minimum (<4 weeks) because of increased risk of secondary fractures. Alternatively, patients with refractures can be treated by surgery, when nonoperative treatment has failed.

Osteoporosis in paediatric patients with spina bifida

“…were the following: fall (35%), transfer (28%), cast immobilization (37%), and unknown (21%). 10 In our previous study, we showed that spontaneous fractures were the principal mechanism of injury (64.4%). 4 Parsch et al have detected 261 fractures in 173 patients from a sample of 1414 patients followed over a 15-year period (1975-1989).…”

“…4,10,15,20,22,23 In SB, fractures occur more frequently below the level of neurological involvement in the paralysed lower extremities, which can be caused by a lack of vertical load.…”

“…6 The period of immobilization after a surgical intervention should be reduced, if possible, 6,15 and weight-bearing should be allowed as soon as possible, 1,10 depending on X-rays signs of consolidation. 10 There is limited evidence that passive weight-bearing in children with SB improves BMD, 25 although standing with the use of a standing frame appears to increase BMD in children with cerebral palsy. 64 In a double-blinded, prospective, randomized, placebo-controlled study including 20 ambulant children with disabilities but no mention of the diagnosis of each child, Ward and colleagues observed that low-magnitude, high-frequency mechanical stimuli increase tibial and spinal volumetric trabecular BMD.…”

“…33 Ausili et al showed that BMD in the lumbar and femoral neck regions was improved in MMC patients who participated in athletic activities in comparison with those who did not. 26 No studies are available concerning the amount of weight bearing and ambulation necessary to maintain or increase BMD 10 to guide prescription of this treatment in patients with SB. For paediatric patients who fail to respond adequately to these general measures, pharmacological therapy for osteoporosis may be considered.…”

“…In the presence of vitamin D deficiency and/or poor dietary calcium intake, it would be suitable to replace such deficits, but routine calcium and vitamin D supplementation is not recommended. 10 4 There is no evidence to substantiate measuring BMD to evaluate fracture probability in paediatric patients with SB. Serious limitations were observed in the number and quality of studies concerning osteoporosis prevention and treatment in paediatric patients with SB.…”