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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 4  |  Issue : 1  |  Page : 40-42

Physiotherapy-related impacted proximal tibia metaphyseal fracture in a child with myelomeningocele


Department of Orthopaedics, Government Medical College, Haldwani, Uttarakhand, India

Date of Submission13-Sep-2015
Date of Acceptance28-Jun-2016
Date of Web Publication1-Feb-2017

Correspondence Address:
Ganesh Singh Dharmshaktu
Department of Orthopaedics, Government Medical College, Haldwani - 263 139, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2394-2010.199331

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  Abstract 

Pediatric cases with myelomeningocele are susceptible to fractures of lower extremities. Impacted proximal tibial metaphyseal fractures are uncommon injuries in pediatric age and peak around 3–6 years of age. Impacted fracture in proximal tibia region consists of periosteal buckling associated with compression load, particularly in metaphyseal area. Proximal tibial is an uncommon site for impacted fractures and the injury pattern in a child with paraplegia associated with myelomeningocele has been a rare report. As the displacement of the fracture is main concern, so a good splinting is the mainstay of treatment. Our report depicts a rare site of fracture in this subset of patients as well as treatment consideration in the form of short-term, light weight and fabricated bracing as the splints. Periodic supervised assessment for recurrence or de novo comorbidities as well as proper nutrition and therapy for osteomalacia is instrumental as part of the holistic management of such cases.

Keywords: Complication, fracture, injury, myelomeningocele, pediatric, physiotherapy, proximal tibia, trauma


How to cite this article:
Dharmshaktu GS. Physiotherapy-related impacted proximal tibia metaphyseal fracture in a child with myelomeningocele . J Health Res Rev 2017;4:40-2

How to cite this URL:
Dharmshaktu GS. Physiotherapy-related impacted proximal tibia metaphyseal fracture in a child with myelomeningocele . J Health Res Rev [serial online] 2017 [cited 2019 Dec 11];4:40-2. Available from: http://www.jhrr.org/text.asp?2017/4/1/40/199331


  Introduction Top


There are several factors that make children with myelomeningocele prone to pathological fractures. Disuse atrophy, decrease bone mass, immobilization, and increased calciuresis are some important factors in this regard.[1] Associated neuropathy has also been implicated for fracture susceptibility as well as repetitive trauma to tender growth plates.[2] Besides it, loss of protective sensation disables anticipation of impending injury or awareness of it after getting injured.[3] Common location of the fractures includes femur while proximal tibia is rather an uncommon site of involvement.[4] The incidence of fractures in cases with myelomeningocele in various studies has been estimated to be 12–31%.[4],[5] A small magnitude of force as trivial as twisting around while sitting or rolling out of bed may cause fracture of a slender skeleton.[5] We present a similar spontaneous fracture in proximal metaphysis of tibia following a scheduled physiotherapy and its conservative management to a successful union.


  Case Report Top


An 8-year-old nonambulatory male child was brought to us with chief complaints of mild swelling over the proximal leg since last 2 days. The child had a history of a swelling over posterior lower back region since birth for which immediate operation was advised. The child underwent an operation at 2 months of age for removal of the swelling and associated repair with guarded prognosis. The lower limbs were paralysed following the operation, and the patient is bed-ridden since then. The upper extremity power is normal to enable him doing self-care and low energy tasks. The child had normal intelligence and higher mental functions. There is delayed growth and asthenic built with height and weight below the average for kids of his age. The pallor was present underlining anemic status, and general examination was normal except abnormal dental structure due to poor dental hygiene. The child had no sensation of pain below the waist and was complete paraplegic with power 0/5 as per Medical Research Council grading of muscle power. There was neither history of any sort of direct trauma nor abuse leading to the present complaints. There was no history of recurrent or multiple fractures in the past. Systemic examination including cardiovascular, respiratory, and genitourinary system as done by pediatric unit was found to be normal. The maternal or paternal history including that of substance abuse, chronic disease, or prolonged medications was unremarkable. The normal delivery was noted with a boggy swelling over lower lumbar region of the neonate, and a diagnosis of meningomyelocele was made as per previous records and the boy was operated at 2 months of age.

There was a history of regular gentle passive range of motion exercises and physiotherapy. As the patient was nonambulatory, his lower limbs were slender and supple. Fortunately, joints like knees or toes were not stiff or deformed as is the usual feature in many patients with paraplegia. The radiograph of his affected leg was taken and showed an undisplaced, metaphyseal fracture of proximal tibia [Figure 1]. The affected site is an uncommon site for such fractures. His contralateral lower limb and pelvic radiographs were unremarkable except thin, slender bones, and mild bilateral hip subluxation [Figure 2]. There was no associated injury or features of fracture at other sites.
Figure 1: Radiograph showing the fracture in proximal tibia metaphysis

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Figure 2: Pelvic radiograph of the same patient showing bilateral hip dysplasia and subluxation

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The patient was advised a knee brace for support during transportation. The plaster cast was avoided with regards to potential complications over nonsensate skin. The passive toe movement was encouraged with full verbal and written explanation of splint care and instructions. Regular checking of skin after transient unfastening of the brace was encouraged. There was no complication related to the injury and the splint noted during the full course of treatment. The fracture showed good, uneventful union on radiograph after 4 weeks [Figure 3]. The splint was discontinued, and gentle physiotherapy resumed with precautions for excessive use of manual force. The prolonged use of splint was not considered a good idea as preventing the excessive forces by education and strengthening bones by pharmacotherapy appears a better idea than using the splint with their own potential complication on a sensate skin as sores, rashes, and blisters. The effect on adjacent joints causing stiffness is another disadvantage of prolonged splinting.
Figure 3: Radiograph showing united fracture in the follow-up

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  Results Top


The uncomplicated healing of fracture was seen on follow-up radiograph at 6 weeks. Passive knee range of motion was smooth. The patient is under supervised physiotherapy schedule and under evaluation by trained orthotist and prosthetist for a holistic approach in treatment. Apart from this a good calcium and Vitamin D supplementation along with other micronutrients were encouraged through diet and medications. The child is under therapy along with active involvement by parents. Follow-up regarding any future healthcare support is well explained to the family.


  Discussion Top


Myelomeningocele has been a serious disabling condition and leading cause of paraplegia even after surgery.[6] Covering of the defect, treating associated hydrocephalus and prevention of infection is routine postnatal management with guarded prognosis.[7] Primary deficits are varying grades of lower limb sensory and motor impairment, bladder and bowel impairment. Patients with thoracic level paraplegia have been found to be increased the risk for fracture.[8] Fracture in cases with myelomeningocele has been found to be related to the neurological level of involvement, i.e. higher incidence with thoracic level and relatively lower incidences with lower lumbar or sacral level ones. Incomplete or complete fracture with an intact periosteum is chief features of injuries as a result of minor trauma in children.[9] Our case was a stable, minimal displaced complete fracture in radiographs. These patterns of fractures are supposed to heal without reported cases of nonunion.

We managed our case with fabricated knee brace avoiding plaster cast and its related complications such as stiffness and skin-related complications. Studies show that rigid immobilization is not mandatory for fracture with stable configuration. Orthotic treatment has been instrumental to avoid deformities and avoid future vocational challenges.[10] Dual energy X-ray absorptiometry scan of the lateral distal femur has been found to be a viable marker for lower limb osteoporosis in these cases.[11] The adequate diagnosis of low lower extremity bone mineral density which is usually present should be managed with medical and musculoskeletal strengthening measures. Apart from it, ancillary care should take to rule out latex allergy in such cases. About 18–40% cases of myelodysplasia may show latex allergy features that may be another important issue in the overall management.[12] Our case never gave a history of any reaction during previous admissions and did not show features of it during or after treatment. There is another concern for rotational deformity either present initially or as a complication of fracture in the area, but the management of both the types has been effectively managed with meticulous derotation osteotomies. A word about such a complication and its future prognosis needs to be explained to the patient.[13] There are evidence that tibial bone mass at ends and diaphysis is low in nonambulatory children as compared to control ones.[14] The management for osteoporosis remains critical in achieving optimal bone health. Besides it, the muscle size and other parameters have been found to be adequately assessed with the help of ultrasonography in these children.[15] Basic and available modalities like treadmill training in nonambulatory kids may improve various health parameters substantially.[16] Our patient, with an uncomplicated fracture pattern, led to an uneventful healing with appropriate care and holistic approach.


  Conclusion Top


A rare site of impacted fracture can be anticipated in cases of myelomeningocele and suspected if localized swelling is perceived in the affected body part. A careful selection of splint and care of skin is warranted for good healing and regular review to check refracture or new fractures.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Marreiros H, Loff C, Calado E. Osteoporosis in paediatric patients with spina bifida. J Spinal Cord Med 2012;35:9-21.  Back to cited text no. 1
    
2.
Gyepes MT, Newbern DH, Neuhauser EB. Metaphyseal and physeal injuries in children with spina bifida and meningomyeloceles. Am J Roentgenol Radium Ther Nucl Med 1965;95:168-77.  Back to cited text no. 2
    
3.
Arkader A, Dormans JP. Pathologic fractures. In: Flynn JM, Skaggs DL, Waters PM, editors. Rockwood and Wilkins' Fractures in Children. 8th ed. Philadelphia: Wolters Kluwer Health; 2015.  Back to cited text no. 3
    
4.
Drennan JC, Freehafer AA. Fractures of the lower extremities in paraplegic children. Clin Orthop Relat Res 1971;77:211-7.  Back to cited text no. 4
    
5.
James CC. Fractures of the lower limbs in spina bifida cystica: A survey of 44 fractures in 122 children. Dev Med Child Neurol Suppl 1970;22 Suppl 22:88.  Back to cited text no. 5
    
6.
Akalan N. Myelomeningocele (open spina bifida) - Surgical management. Adv Tech Stand Neurosurg 2011;(37):113-41.  Back to cited text no. 6
    
7.
Adzick NS, Walsh DS. Myelomeningocele: Prenatal diagnosis, pathophysiology and management. Semin Pediatr Surg 2003;12:168-74.  Back to cited text no. 7
    
8.
Akbar M, Bresch B, Raiss P, Fürstenberg CH, Bruckner T, Seyler T, et al. Fractures in myelomeningocele. J Orthop Traumatol 2010;11:175-82.  Back to cited text no. 8
    
9.
Loder RT, Hensinger RN. Slipped capital femoral epiphysis associated with renal failure osteodystrophy. J Pediatr Orthop 1997;17:205-11.  Back to cited text no. 9
    
10.
Lebek S, Seidel U, Damerau M, Perka C, Funk JF. Orthopaedic treatment for patients with myelomeningocele. Z Orthop Unfall 2015;153:423-32.  Back to cited text no. 10
    
11.
Haas RE, Kecskemethy HH, Lopiccolo MA, Hossain J, Dy RT, Bachrach SJ. Lower extremity bone mineral density in children with congenital spinal dysfunction. Dev Med Child Neurol 2012;54:1133-7.  Back to cited text no. 11
    
12.
Preventing allergic reactions to natural rubber latex in the workplace. (DHHS Publication No. 97-135). Washington, DC: U.S. Government Printing Office; 1997. p. 97-135.  Back to cited text no. 12
    
13.
Mednick RE, Eller EB, Swaroop VT, Dias L. Outcomes of tibial derotational osteotomies performed in patients with myelodysplasia. J Pediatr Orthop 2015;35:721-4.  Back to cited text no. 13
    
14.
Horenstein RE, Shefelbine SJ, Mueske NM, Fisher CL, Wren TA. An approach for determining quantitative measures for bone volume and bone mass in the pediatric spina bifida population. Clin Biomech (Bristol, Avon) 2015;30:748-54.  Back to cited text no. 14
    
15.
Rahmani N, Mohseni-Bandpei MA, Vameghi R, Salavati M, Abdollahi I. Application of ultrasonography in the assessment of skeletal muscles in children with and without neuromuscular disorders: A systematic review. Ultrasound Med Biol 2015;41:2275-83.  Back to cited text no. 15
    
16.
Christensen C, Lowes LP. Treadmill training for a child with spina bifida without functional ambulation. Pediatr Phys Ther 2014;26:265-73.  Back to cited text no. 16
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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