Fractures in Patients with Cerebral Palsy

McIVOR, WILLIAM C.; Samilson, Robert L.

doi:10.2106/00004623-196648050-00003

Cited by 64 publications

(46 citation statements)

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“…The incidence of malunion in fractures treated operatively was 20% (2/10) and was even higher in fractures treated non-operatively at 32% (12/37). These rates are higher than those reported in the studies reviewed by Wright [12], who studied normal children, but are not as high as the rates reported for traumatic braininjured children or the rates reported by McIvor and Samilson 30 years ago for children with cerebral palsy [1].…”

Section: Discussioncontrasting

confidence: 67%

Treatment of femur fractures in children with cerebral palsy

Leet

Shirley

Barker

et al. 2009

Journal of Children's Orthopaedics

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Purpose Children with cerebral palsy may have low bone density stemming from various etiologies and are, thereby, at risk for fractures. The treatment of femur fractures in children with cerebral palsy may need to be tailored to address the management of spastic muscle tone and multiple medical co-morbidities. Methods Our study is a retrospective review that evaluates the treatment of 47 femur fractures in children with cerebral palsy in both ambulatory and non-ambulatory patients.Results Thirty-two fractures in non-ambulators were treated non-operatively, 11 of which resulted in malunions and five developed pressure sores. Six fractures in nonambulators were treated operatively, one of which resulted in a malunion. In ambulators, five fractures were treated non-operatively; one of these fractures lost reduction after 2 weeks and required surgical intervention. One of four fractures in ambulators treated operatively developed a malunion. Conclusion Our study results suggest that femur fractures in children with cerebral palsy can be treated non-operatively; however, because of the high risk of malunion in this patient population, fracture alignment needs to be followed closely during healing. Careful attention during casting is necessary to prevent pressure sores. Strong consideration should be given to initial operative treatment in ambulatory patients in order to preserve function.

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Section: Discussioncontrasting

confidence: 67%

Treatment of femur fractures in children with cerebral palsy

Leet

Shirley

Barker

et al. 2009

Journal of Children's Orthopaedics

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“…Consistent with this, fractures in children with these conditions usually involve the limbs, particularly the femur, and virtually never occur in the spine. 2,3,47 In this study, it was found that BMD z scores in the lumbar spine and distal femur were not identically related to the other factors. For example, use of anticonvulsants did correlate with BMD z scores in the distal femur but not in the lumbar spine.…”

Section: Discussionmentioning

confidence: 56%

“…[1][2][3] Low bone density, stiff joints, poor balance leading to falls, and violent seizures are factors that can contribute to fractures in this population. The most common site of fracture is the femur.…”

mentioning

confidence: 99%

Bone Density and Metabolism in Children and Adolescents With Moderate to Severe Cerebral Palsy

Lark²,

et al. 2002

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ABSTRACT. Objectives. Diminished bone density and a propensity to fracture with minimal trauma are common in children and adolescents with moderate to severe cerebral palsy (CP). The purpose of this study was to provide a detailed evaluation of bone mineral density (BMD) and metabolism in this population and to assess the relationship of these measures to multiple other clinical, growth, and nutrition variables.Methods. The study group consisted of 117 subjects ages 2 to 19 years (mean: 9.7 years) with moderate to severe CP as defined by the Gross Motor Functional Classification scale. Population-based sampling was used to recruit 62 of the participants, which allows for estimations of prevalence. The remaining 55 subjects were a convenience sampling from both hospital-and school-based sources. The evaluation included measures of BMD, a detailed anthropometric assessment of growth and nutritional status, medical and surgical history, the Child Health Status Questionnaire, and multiple serum analyses. BMD was measured in the distal femur, a site specifically developed for use in this contracted population, and the lumbar spine. BMD measures were converted to age and gender normalized z scores based on our own previously published control series (n > 250).Results. Osteopenia (BMD z score <؊2.0) was found in the femur of 77% of the population-based cohort and in 97% of all study participants who were unable to stand and were older than 9 years. BMD was not as low in the lumbar spine (population-based cohort mean ؎ standard error z score: ؊1.8 ؎ 0.1) as in the distal femur (mean z score: ؊3.1 ؎ 0.2). Fractures had occurred in 26% of the children who were older than 10 years. Multiple clinical and nutritional variables correlated with BMD z scores, but interpretation of these findings is complicated by covariance among variables. In stepwise regression analyses, it was found that severity of neurologic impairment as graded by Gross Motor Functional Classification level, increasing difficulty feeding the child, use of anticonvulsants, and lower triceps skinfold z scores (in decreasing order of importance) all independently contribute to lower BMD z scores in the femur.Conclusions. Low BMD is prevalent in children with moderate to severe CP and is associated with significant fracture risk. The underlying pathophysiology is complex, with multiple factors contributing to the problem and significant variation between different regions of the skeleton. Pediatrics 2002;110(1). URL: http://www. pediatrics.org/cgi/content/full/110/1/e5; cerebral palsy, bone mineral density, osteoporosis, pediatrics, bone metabolism, growth, nutrition, osteopenia.

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“…This is likely to be related to the fact that non-ambulatory children with a chronic severe disability have low bone mineral density 18 with subsequent morbidity. 19 In our study, the most common site of fracture was the distal femur. An analysis of the literature shows that this is the most common site of fractures in children with immobility, independent of the primary disease.…”

Section: Discussionmentioning

confidence: 60%

“…An analysis of the literature shows that this is the most common site of fractures in children with immobility, independent of the primary disease. 19,20 The sites of fractures in patients with spina bifida were similar to those encountered in patients with spinal-cord injury. 21 We failed to find verte- bral fractures, which suggests a possible protective effect on vertebral fractures among patients with spina bifida who use wheelchairs.…”

Section: Discussionmentioning

confidence: 67%

Fractures in children and adolescents with spina bifida: the experience of a Portuguese tertiary‐care hospital

Marreiros

Monteiro

Loff

et al. 2010

Develop Med Child Neuro

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AIM The morbidity associated with osteoporosis and fractures in children and adolescents with spina bifida highlights the importance of osteoporosis prevention and treatment in these patients. The aim of this study was to examine the occurrence and pattern of bone fractures in paediatric patients with spina bifida.METHOD We reviewed the data of all paediatric patients with spina bifida who were treated in our centre between 1999 and 2008.RESULTS One hundred and thirteen patients were included in the study (63 females, 50 males; mean age 10y 8mo, SD 4y 10mo, range 6mo-18y). The motor levels were thoracic in six, upper lumbar in 22, lower lumbar in 42, and sacral in 43 patients. Of the 113 patients, 58 (51.3%) had shunted hydrocephalus. Thirty-six (31.8%) were non-ambulatory (wheelchair-dependent [unable to self-propel wheelchair] n=3, wheelchair-independent [able to self-propel wheelchair] n=33), 13 were partial ambulators, 61 were full ambulators, and three were below the age of walking. Fortyfive fractures were reported in 25 patients. The distal femur was the most common fracture site. Statistical analyses showed that patients with higher levels of involvement and in wheelchairs had a significantly increased risk of having a second fracture (p<0.001). Spontaneous fractures were the principal mechanism of injury, and an association was identified between fracture mechanism, type of ambulation, and lesion level: the fractures of patients with higher levels of motor functioning and those in wheelchairs were mainly pathological (p=0.01). We identified an association between risk of a second fracture, higher motor level lesion, and non-ambulation. There was an increased risk of having a second fracture after a previous spontaneous fracture (p=0.004).INTERPRETATION Data in this study indicate a high prevalence of fractures in patients with spina bifida.In congenital paraplegia caused by myelomeningocele, the body lacks the usual axial burden on the legs, muscular activity, and sensation. 1 There is a direct influence of working muscles on the remodelling process of the growing tibia. Postmortem studies of patients with spina bifida reveal a thin and atrophic cortex of the tibia with a diminished number of Haversian systems and large remodelling cavities. 2 In fact, patients with spina bifida have lower bone mineral density and are at risk of pathological bone fractures. 3 The clinical status of children with spina bifida can be significantly worsened by the effects of secondary osteoporosis, including fractures and subsequent further immobilization, and the leg bones of patients with spina bifida have an additional risk of fractures after inactivity (e.g. postoperatively). 1,[4][5][6] Our primary aim in this study was to examine the frequency and characteristics of fractures in paediatric patients with spina bifida. A secondary aim was to identify other variables that may contribute to the presence of fractures, such as neurological level, shunted hydrocephalus, syringomyelia, type of ambulation, mechanism of injury...

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Fractures in Patients with Cerebral Palsy

Cited by 64 publications

References 0 publications

Treatment of femur fractures in children with cerebral palsy

Treatment of femur fractures in children with cerebral palsy

Bone Density and Metabolism in Children and Adolescents With Moderate to Severe Cerebral Palsy

Fractures in children and adolescents with spina bifida: the experience of a Portuguese tertiary‐care hospital

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