ORIGIN AND TREATMENT OF FRACTURES IN SPINA-BIFIDA

Children with spina bifida cystica have a high risk of fracturing their paraplegic legs. During the last fifteen years we observed 261 fractures and epiphyseal injuries in 173 children out of 1,400 (12.2%) patients with spina bifida. The increased risk of fracture seems to be due to reduced muscle activity in the paralysed limb with insufficient axial loading of the legs. A large proportion of fractures occurs after orthopedic interventions. Fractures are less common after urologic or neurosurgical procedures. Breaks are extremely frequent after operations in association with cast immobilization. Early standing and short immobilization times are the best defence mechanisms against fractures. If plasters are needed postoperatively one should preferably use the "Max and Moritz" standing cast. Fractures in spina bifida children heal quickly as compared to those in non-paralyzed children. In 30% excessive callus is seen. Immobilization for fracture care can be done in a standing cast even in the very early phase of treatment. In spite of the swelling and elevated temperature axial loading in the standing cast should continue. Splints and braces can be used instead of the plaster cast. By any means, the vicious circle of Fracture-Plaster-Fracture-Plaster should be avoided. Repeated stress on the growth plate causes a mechanism of loosening. The most common site is the distal tibia and femur, less often loosenings occur in the proximal tibia and proximal femur. Epiphyseal loosening is a nosological entity seen in spina bifida and also in congenital absence of sensation. Distal tibial epiphyseal loosening is frequently seen in adolescents who have learned to walk only after muscle balancing procedures in the hips. Subsequent premature closure of the growth plate must be anticipated. If the epiphyseolysis is seen in young children surgical fixation is suggested.