Incidence, prevalence, and characteristics of fractures in children, adolescents, and adults with spina bifida

Orthopaedic Fractures among Patients Attending a Tertiary Care Centre

Introduction

Orthopedic fractures caused by chronic metabolic bone disease, overuse, or road traffic accidents are among the most significant burdens on society. Furthermore, a growing number of people undergoing arthroplasty and an increase in life expectancy seem to contribute to an increase in orthopaedic fractures. However, research on orthopaedic fracture prevalence or types has been scarce in low- and middle-income countries, including Nepal. The objective of this study was to find out the prevalence of orthopaedic fractures among patients attending a tertiary care centre.

Methods

A descriptive cross-sectional study among patients attending a tertiary care centre was conducted between 19 May and 18 November 2023 during which date from 1 January to 30 December 2021 were collected from the hospital records. Ethical approval was obtained from the Institutional Review Committee. A convenience sampling method was used. Point estimate was calculated at a 95% Confidence Interval.

Results

Among 7609 people, 2518 (33.09%) (12.97-10.55, 95% Confidence Interval) had orthopaedic fractures. A total of 1925 (76.45%) were males. There were 339 (95.49%) fractures associated with two-wheelers and 307 (86.48%) with four-wheelers. There were 1387 (55.08%) soft tissue injuries, 198 (7.86%) skull injuries, and 116 (4.61%) facial injuries. Additionally, there were 73 (2.90%) fractures of the femur, 71 (2.82%) fractures of the phalanx, and 70 (2.78%) fractures of the clavicle.

Conclusions

The prevalence of orthopaedic fractures was found to be higher than in other studies done in similar settings.

Keywords

bone fracture; orthopedics; prevalence; tertiary care centre.

Risk factors for unanticipated hospitalizations in children and youth with spina bifida at an urban children's hospital: A cross-sectional study

BACKGROUND

Spina bifida (SB) is a condition resulting from the improper closure of the neural tube and vertebral column during fetal development. While patients' life expectancy and quality of life have improved dramatically due to medical advances, children continue to experience health-related issues that often require hospitalizations.

OBJECTIVE

The association among sociodemographic and clinical characteristics with potentially preventable hospitalizations (PPH) in children and youth with myelomeningocele type SB was investigated in this cross-sectional study.

METHODS

Chart reviews and data extraction were conducted on 108 children and youth, ages 1 month to 21 years, admitted for PPH in a regional children's academic medical center between May 2017 and July 2019. Sociodemographic variables included sex, age, type of insurance and ethnicity. Clinical variables included level of lesion, ambulation status, shunt dependency and selected diagnostic categories. Univariate, bivariate, and multivariate analyses were conducted to identify factors associated with PPH.

RESULTS

Factors associated with PPH included being male, ages 5-18 years, low lumbar level lesions, non-ambulatory, with public insurance, Hispanic and shunt dependent. Most hospitalizations (73%) were for neurologic or urologic conditions. Factors independently associated with PPH were ethnicity for urologic conditions, being ambulatory for metabolic conditions, and age for gastroenterology conditions.

CONCLUSION

Selected demographic and clinical variables were found to be associated with PPH of children and youth with myelomeningocele-type SB. The most common reasons for PPH were shunt malfunctions and urinary tract infections, consistent with other studies.

Independently ambulatory children with spina bifida experience near-typical knee and ankle joint moments and forces during walking

BACKGROUND

Spina bifida, a neurological defect, can result in lower-limb muscle weakness. Altered ambulation and reduced musculoskeletal loading can yield decreased bone strength in individuals with spina bifida, yet individuals who remain ambulatory can exhibit normal bone outcomes.

RESEARCH QUESTION

During walking, how do lower-limb joint kinematics and moments and tibial forces in independently ambulatory children with spina bifida differ from those of children with typical development?

METHODS

We retrospectively analyzed data from 16 independently ambulatory children with spina bifida and 16 children with typical development and confirmed that tibial bone strength was similar between the two groups. Plantar flexor muscle strength was measured by manual muscle testing, and 14 of the children with spina bifida wore activity monitors for an average of 5 days. We estimated tibial forces at the knee and ankle using motion capture data and musculoskeletal simulations. We used Statistical Parametric Mapping t-tests to compare lower-limb joint kinematic and kinetic waveforms between the groups with spina bifida and typical development. Within the group with spina bifida, we examined relationships between plantar flexor muscle strength and peak tibial forces by calculating Spearman correlations.

RESULTS

Activity monitors from the children with spina bifida reported typical daily steps (9656 [SD 3095]). Despite slower walking speeds (p = 0.004) and altered lower-body kinematics (p < 0.001), children with spina bifida had knee and ankle joint moments and forces similar to those of children with typical development, with no detectable differences during stance. Plantar flexor muscle weakness was associated with increased compressive knee force (p = 0.002) and shear ankle force (p = 0.009).

SIGNIFICANCE

High-functioning, independently ambulatory children with spina bifida exhibited near-typical tibial bone strength and near-typical step counts and tibial load magnitudes. Our results suggest that the tibial forces in this group are of sufficient magnitudes to support the development of normal tibial bone strength.

Health Concerns of Adolescents and Adults With Spina Bifida

Due to advancements in medical care, people with spina bifida (SB) are surviving well into adulthood, resulting in a growing number of patients transitioning to an adult sector unequipped to care for people with chronic rehabilitative and medical needs. The Transitional and Lifelong Care (TLC) program is a multidisciplinary clinical service that compensates for this gap, providing comprehensive, coordinated care to adolescents, and adults with SB. As a relatively new clinical service, objective data about the patients using the service and their needs is scant. This study sought to identify the most common health concerns among TLC patients with SB at initial clinical consultation. A retrospective chart review of 94 patient charts was performed. Following data extraction, descriptive analyses were completed. The mean age of the sample was 29.04 ± 13.8 years. One hundred individual concerns and 18 concern categories were identified. On average, patients or care providers identified nine health concerns across various spheres of care, with care coordination being the most prevalent concern identified (86%). Patients also commonly had concerns regarding neurogenic bladder (70%), medications (66%), assistive devices (48%), and neurogenic bowel (42%). The numerous and wide-ranging health concerns identified support the need for individualised, coordinated care and a "medical home" for all adolescents and adults with SB during and following the transition to adult care. Health care providers caring for this population should continue to address well-documented health concerns and also consider raising discussion around topics such as sexual health, mental health, and bone health. Further research is required to understand how best to address the complex medical issues faced by adults with SB to maximise health and quality of life and improve access to healthcare.

Quantitative Computed Tomography Assessment of Bone Deficits in Ambulatory Children and Adolescents with Spina Bifida: Importance of Puberty

Pathologic fractures of the femur and tibia are common in youth with spina bifida (SB). These fractures may be associated with deficient bone accrual due to decreased ambulation and skeletal loading. This prospective cohort study used quantitative computed tomography (QCT) to assess three-dimensional (3D) bone properties in children and adolescents with SB. Eighty-three ambulatory youth with SB underwent QCT imaging of the tibia at up to four annual visits between ages 6 to 16 years (294 total visits averaging 3.5 visits/patient). A total of 177 controls without disability and 10 non-ambulatory youth with SB underwent imaging once. Bone geometric properties (cortical bone area, cross-sectional area, cortical thickness, cortical density, and moments of inertia) were measured at the mid-diaphysis (50% of bone length); cross-sectional area, cancellous density, and density-weighted area were measured in the proximal (13% of bone length) and distal (90% of bone length) metaphyses. Bone properties were compared between the ambulatory SB and control participants, among SB neurosegmental subgroups (sacral, low lumbar, mid lumbar and above) as a function of pubertal stage (prepubertal, pubertal, postpubertal), and considering SB type (myelomeningocele, lipomyelomeningocele) using linear mixed effects models adjusted for sex, age, height percentile, and body mass index (BMI) percentile. Only cancellous density of both metaphyses and weighted area of the proximal metaphysis differed between ambulatory children with SB and controls before puberty. However, significant deficits in all bone properties manifested during and after puberty as moderate bone growth in the SB group failed to keep pace with the large increases normally observed during puberty. The bone deficits primarily affected patients with myelomeningocele, and similar deficits were observed at all neurosegmental levels except that cancellous density was closer to normal in the sacral group. Descriptive analysis of the 10 non-ambulatory youth with SB showed greater bone deficits than ambulatory children, particularly for cancellous density in the distal metaphysis. © 2020 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Age-specific occurrence of pathological fractures in patients with spina bifida

Pathological fractures (PFs) are common in patients with spina bifida. However, most previous studies refer to the overall fracture rate and largely neglecting putative age-dependent aspects. The aim of this retrospective study was to characterize patterns of fracture occurrence in childhood. In a retrospective study, we identified PF, all in the lower limbs, in 13% of 210 patients with spina bifida aperta. We further identified a bimodal frequency distribution of pathological fractures, with peaks at 1-5 and 10-12 years. We could thereby distinguish two groups of patients: (i) Children with a first fracture before an age of 6 years developed frequently multiple fractures within the following years, but fracture series typically stopped by 6 years-of-age. (ii) Children with a first fracture after the age of 6 years had fewer fractures, but these occurred also in adolescence. PF occurred rarely after the age of 13 years. The age at fracture correlated with the fracture site with 85% of the fractures occurring in the femur in the first five years of life and an increased frequency of tibia and foot fractures later in life. While, overall high lesion levels and preceding immobilizing events were risk factors for PF, femur fractures in children under 6 years-of-age occurred independent of their lesion level, and the age at verticalization did not correlate with PF rates.Conclusion: Based on these findings, standardized and effective preventive physiotherapeutic and/or pharmacological interventions to tackle PF in spina bifida need to consider age-specific differences in occurrence and reoccurrence of fractures.What is Known:• Pathological fractures are common in patients with spina bifida aperta, and associated risk factors include high lesion level, immobilization and low bone density.What is New:• We first report a bimodal frequency distribution of pathological fractures in childhood (first peak 1-5 years, second peak 10-12 years) and link early-onset fracture occurrence with the risk of multiple fractures arise in a short time period but a the chance of self-limitation of fracture series within a few years.• We show that femur fractures in children under 6 years-of-age occurred independent of their lesion level, and the age at verticalization did not correlate with PF rates.• We further link the age-dependent occurrence pattern with the risk of further fractures and with the chance of self-limitation of fracture series. The earlier a first fracture occurs, the more probable multiple fractures arise in a short time period. Nevertheless, early fracture series are often self-limiting within a few years.• Femur fractures in children under 6 years-of-age occurred independent of their lesion level, and the age at verticalization did not correlate with PF rates.• Based on these findings, physiotherapeutic and/or pharmaceutical concepts need to be developed in an age-adapted manner and in consideration of the potential self-limiting nature of fracture series.

Children with myelomeningocele do not exhibit normal remodeling of tibia roundness with physical development

Skeletal loading through daily movement is an important factor in the normal development of bones. This loading is affected by the neurological and muscle deficits that result from myelominingocele (MM). While children with MM have been shown to have atypical gait, decreased bone accrual, and increased fracture risk, it is still unclear what morphological bone differences exist and to what extent they relate to physical developmental and ambulation level. This study analyzed computed tomography images of the tibia from 77 children with MM and 124 typically developing (TD) children between the ages of 6 and 16 years. Differences in cross-sectional roundness along the length of the tibia diaphysis were observed across developmental stages (pre-pubertal, pubertal, post-pubertal) and ambulation level (MM non-ambulatory, MM assistive devices, MM independent, and TD). The results showed that tibia cross-sectional morphology becomes less round with development in TD children (p < 0.017). In children with MM, however, roundness is maintained throughout adolescence (p > 0.017), with greater roundness in less ambulatory children (p < 0.0083). These in vivo results align with mechanobiological modeling studies suggesting that intracortical loads (caused by joint loading) as well as periosteal loads (imposed by surrounding muscles) are critical in promoting non-circular cross-sectional bone shape remodeling.

Update on bone fragility in spina bifida

BACKGROUND CONTEXT

Patients with spina bifida (SB) are at risk for pathological fractures and low bone mineral density (BMD).

PURPOSE AND METHODS

This article reviews the literature and provides a comprehensive overview of how the characteristics of SB and its associated comorbidities intersect with bone fragility to identify possible pathophysiological mechanisms of fractures and low BMD.

RESULTS

Bone fragility occurs early in the life of patients with SB as a result of a disturbance that determines changes in bone shape, quantity, and quality, as poor mineralization reduces bone stiffness. Bone fragility in SB occurs due to local and systemic factors and may be considered a state of impaired bone quality of multifactorial aetiology, with complex interacting influences of neurological, metabolic, and endocrinological origins and the presence of smaller bones. Bone fragility should be evaluated globally according to skeletal age and Tanner staging. The phases of the evolution of Charcot joints seem to intercept the evolution of epiphyseal fractures. Charcot arthropathy in SB may be initiated by the occurrence of repetitive trauma and fractures in epiphyseal and subepiphyseal regions, where there is a deficit of bone mineralization and greater bone mass deficits.

CONCLUSION

Bone fragility in MMC potentially has a multifactorial neuro-endocrinological-metabolic-renal dimension, with smaller bones, lower bone mass, and mineralization deficits affecting bone strength.

Muscle-Bone Interactions in Pediatric Bone Diseases

PURPOSE

Here, we review the skeletal effects of pediatric muscle disorders as well as muscle impairment in pediatric bone disorders.

RECENT FINDINGS

When starting in utero, muscle disorders can lead to congenital multiple contractures. Pediatric-onset muscle weakness such as cerebral palsy, Duchenne muscular dystrophy, spinal muscular atrophy, or spina bifida typically are associated with small diameter of long-bone shafts, low density of metaphyseal bone, and increased fracture incidence in the lower extremities, in particular, the distal femur. Primary bone diseases can affect muscles through generic mechanisms, such as decreased physical activity or in disease-specific ways. For example, the collagen defect underlying the bone fragility of osteogenesis imperfecta may also affect muscle force generation or transmission. Transforming growth factor beta released from bone in Camurati Engelman disease may decrease muscle function.

FUTURE DIRECTIONS

Considering muscle-bone interactions does not only contribute to the understanding of musculoskeletal disorders but also can identify new targets for therapeutic interventions.

Fat-Bone Interactions in Adults With Spina Bifida

Context:

Spina bifida (SB) can lead to changes in body composition and bone mineral density (BMD) through diminished ambulation, renal impairment, and anticonvulsant medication. With increased life expectancy, diseases such as obesity and osteoporosis are emerging comorbidities in SB, with limited data to guide management.

Objective:

To examine the relationship between cardiometabolic factors, body composition, BMD, and minimal trauma fractures (MTFs) in adults with SB.

Design:

Retrospective cross-sectional study.

Setting and Participants:

Forty-nine adults with SB (median age, 32.7 years; interquartile range, 22.6 to 39.0) who had undergone dual-energy x-ray absorptiometry imaging at a single tertiary hospital from 2004 to 2015.

Results:

The mean body mass index was 31.7 ± 7.5 kg/m2; 26 (53.1%) were obese. Using age- and sex-matched fat percentiles from the National Health and Nutrition Examination Survey III, 62.5% had a total body percentage fat greater than the 95th percentile. Low bone mass (defined as a Z-score of ≤−2.0) was present in 21.9% at the L1 vertebra and in 35.1% at the femoral neck. Ten (20.4%) had a history of MTFs. A BMD or Z-score at L1, femoral neck, or total body site did not correlate with the occurrence of MTF. Fat mass was significantly and positively associated with BMD after adjustment for age, sex, and height and accounted for 18.6% of the variance in BMD (P = 0.005). The prevalence of metabolic comorbidities, such as hypertension (20.4%) and obstructive sleep apnea (16.3%), was high.

Conclusions:

Obesity and low BMD are common in young adults with SB. An increased fat mass correlated significantly with BMD. The prevalence of metabolic complications in patients with SB is increased and deserves further study.

Risk factors for poor bone health in primary mitochondrial disease

INTRODUCTION

Primary mitochondrial disease is caused by either mitochondrial or nuclear DNA mutations that impact the function of the mitochondrial respiratory chain. Individuals with mitochondrial disorders have comorbid conditions that may increase their risk for poor bone health. The objective of this retrospective electronic medical record (EMR) review was to examine risk factors for poor bone health in children and adults with primary mitochondrial disease.

METHODS

Eighty individuals with confirmed clinical and genetic diagnoses of primary mitochondrial disease at the Children's Hospital of Philadelphia (CHOP) were included in this study. Risk factors and bone health outcomes were collected systematically, including: anthropometrics (low BMI), risk-conferring co-morbidities and medications, vitamin D status, nutrition, immobility, fracture history, and, where available, dual energy x-ray absorptiometry (DXA) bone mineral density (BMD) results.

RESULTS

Of patients 73% (n = 58) had at least one risk factor and 30% (n = 24) had four or more risk factors for poor bone health. The median number of risk factors per participant was 2, with an interquartile interval (IQI 0-4). In the subset of the cohort who were known to have sustained any lifetime fracture (n = 11), a total of 16 fractures were reported, six of which were fragility fractures, indicative of a clinically significant decrease in bone strength.

CONCLUSIONS

The prevalence of risk factors for poor bone health in primary mitochondrial disease is high. As part of supportive care, practitioners should address modifiable risk factors to optimize bone health, and have a low threshold to evaluate clinical symptoms that could suggest occult fragility fracture.

Muscle abnormalities in osteogenesis imperfecta

Osteogenesis imperfecta (OI) is mainly characterized by bone fragility but muscle abnormalities have been reported both in OI mouse models and in children with OI. Muscle mass is decreased in OI, even when short stature is taken into account. Dynamic muscle tests aiming at maximal eccentric force production reveal functional deficits that can not be explained by low muscle mass alone. However, it appears that diaphyseal bone mass is normally adapted to muscle force. At present the determinants of muscle mass and function in OI have not been clearly defined. Physiotherapy interventions and bisphosphonate treatment appear to have some effect on muscle function in OI. Interventions targeting muscle mass have shown encouraging results in OI animal models and are an interesting area for further research.

Fractures in spina bifida from childhood to young adulthood

This study assessed the prevalence and types of fractures in spina bifida and examined risk factors for fracture. Fracture prevalence was highest in childhood and reduced in adolescence and young adulthood. The importance of maintaining mobility is highlighted by the increased risk of fracture in those who are non-ambulatory.

INTRODUCTION

The aims of this study are to study the prevalence and types of fractures according to age group in spina bifida and examine risk factors associated with fracture.

METHODS

This is a retrospective cohort study of 146 individuals with spina bifida aged 2 years or older who attended the paediatric or adult spina bifida multidisciplinary clinic at a single tertiary hospital.

RESULTS

Median age at which first fracture occurred was 7 years (interquartile range 4-13 years). Fracture rates in children (ages 2-10), adolescents (ages 11-18) and adults (age > 18) were 10.9/1000 (95 % confidence interval 5.9-18.3), 5.4/1000 (95 % CI 1.5-13.8) and 2.9/1000 (95 % CI 0.6-8.1) patient years respectively. Childhood fractures predominantly involved the distal femur and femoral shaft; these fractures were rarely seen in adulthood. Non-ambulatory status was associated with a 9.8 times higher risk of fracture compared with ambulatory patients (odds ratio 9.8, p = 0.016, 95 % CI 1.5-63.0). Relative risk of re-fracture was 3.1 (95 % CI 1.4-6.8). Urological intervention with intestinal segments was associated with renal calculi (p = 0.037) but neither was associated with fracture.

CONCLUSIONS

The risk of fracture is lower in adults compared with children with spina bifida. The predominant childhood fracture affects the distal femur, and immobility is the most significant risk factor for fracture. Clinical factors contributing to fracture risk need to be elucidated to enable selection of patients who require investigation and treatment of osteoporosis.

The management of osteoporosis in children

This article reviews the manifestations and risk factors associated with osteoporosis in childhood, the definition of osteoporosis and recommendations for monitoring and prevention. As well, this article discusses when a child should be considered a candidate for osteoporosis therapy, which agents should be prescribed, duration of therapy and side effects. There has been significant progress in our understanding of risk factors and the natural history of osteoporosis in children over the past number of years. This knowledge has fostered the development of logical approaches to the diagnosis, monitoring, and optimal timing of osteoporosis intervention in this setting. Current management strategies are predicated upon monitoring at-risk children to identify and then treat earlier rather than later signs of osteoporosis in those with limited potential for spontaneous recovery. On the other hand, trials addressing the prevention of the first-ever fracture are still needed for children who have both a high likelihood of developing fractures and less potential for recovery. This review focuses on the evidence that shapes the current approach to diagnosis, monitoring, and treatment of osteoporosis in childhood, with emphasis on the key pediatric-specific biological principles that are pivotal to the overall approach and on the main questions with which clinicians struggle on a daily basis. The scope of this article is to review the manifestations of and risk factors for primary and secondary osteoporosis in children, to discuss the definition of pediatric osteoporosis, and to summarize recommendations for monitoring and prevention of bone fragility. As well, this article reviews when a child is a candidate for osteoporosis therapy, which agents and doses should be prescribed, the duration of therapy, how the response to therapy is adjudicated, and the short- and long-term side effects. With this information, the bone health clinician will be poised to diagnose osteoporosis in children and to identify when children need osteoporosis therapy and the clinical outcomes that gauge efficacy and safety of treatment.

Risk of fracture prevention in spina bifida patients: correlation between bone mineral density, vitamin D, and electrolyte values

PURPOSE

The aim of our study was to investigate the relationship between bone mineral density (BMD), vitamin D, and electrolyte blood values in patients with spina bifida, to find a possible therapeutic regimen and an intervention to reduce the risk of fractures in this population.

METHODS

BMD values were measured in 49 patients (32 females, 17 males; aged 14.1 ± 3.86 years; range 5-20 years) using dual-energy X-ray absorptiometry (DEXA) and were analyzed based on sex, the level of spinal involvement, vitamin D, and electrolyte values, physical activity, body mass index (BMI), and ambulatory status [patients were divided into three subgroups: full-time wheelchair (FTWC), limited ambulator (LA), and full-time ambulator (FTA)]. These data were analyzed considering sex-, age-, and BMD-matched values and compared with those of normal population.

RESULTS

BMD was significantly lower in these patients compared with that in the general healthy population (Z-score: -1.2 ± 1.8); in particular, females had Z-score values significantly lower that of the males (Z-score: -2.43 ± 2.02; P < 0.0004). In FTWC subgroup, Z-score was lower than that of the other two subgroups (P < 0.009). Vitamin D values were significantly lower compared with those in the general healthy population (vitamin D spina bifida group: 14.6 ± 8.7 mg/dL; normal subjects: 35 ± 9.8 mg/dL; P < 0.001). Subjects with spina bifida showed hypophosphatemia (<3 mg/dL) because of the lower levels of vitamin D (3.1 ± 0.9 mg/dL; P < 0.001).

CONCLUSIONS

Spina bifida patients showed lower BMD, vitamin D, and electrolyte values than the healthy population; hence, they have an increase risk of developing pathological fractures. Vitamin D supplementation for a longer time period could reduce this risk.

Examination of the relationship between body mass index (BMI) and functional independence level in children with spina bifida

OBJECTIVE

The aim of this study is to examine the relationship between body mass index (BMI) and functional independence level in children with spina bifida (SB).

METHODS

The study included 116 children between 5 and 18 years. Subjects' socio-demographic characteristics, BMI values and functional independence levels were recorded.

RESULTS

There was negative correlation between BMI and communication and social cognition in girls (p < 0.05). No correlation was found between BMI and WeeFIM in boys (p > 0.05).

CONCLUSION

The results indicated that body weight in children with SB affected functional independency and that precautions to control weight important in these children.

Neuromuscular training based on whole body vibration in children with spina bifida: a retrospective analysis of a new physiotherapy treatment program

INTRODUCTION

Spina bifida is the most common congenital cause of spinal cord lesions resulting in paralysis and secondary conditions like osteoporosis due to immobilization. Physiotherapy is performed for optimizing muscle function and prevention of secondary conditions. Therefore, training of the musculoskeletal system is one of the major aims in the rehabilitation of children with spinal cord lesions.

INTERVENTION AND METHODS

The neuromuscular physiotherapy treatment program Auf die Beine combines 6 months of home-based whole body vibration (WBV) with interval blocks at the rehabilitation center: 13 days of intensive therapy at the beginning and 6 days after 3 months. Measurements are taken at the beginning (M0), after 6 months of training (M6), and after a 6-month follow-up period (M12). Gait parameters are assessed by ground reaction force and motor function by the Gross Motor Function Measurement (GMFM-66). Sixty children (mean age 8.71 ± 4.7 years) who participated in the program until February 2014 were retrospectively analyzed.

RESULTS

Walking velocity improved significantly by 0.11 m/s (p = 0.0026) and mobility (GMFM-66) by 2.54 points (p = 0.001) after the training. All changes at follow-up were not significant, but significant changes were observed after the training period. Decreased contractures were observed with increased muscle function.

CONCLUSION

Significant improvements in motor function were observed after the active training period of the new neuromuscular training concept. This first analysis of the new neuromuscular rehabilitation concept Auf die Beine showed encouraging results for a safe and efficient physiotherapy treatment program which increases motor function in children with spina bifida.

Bisphosphonate treatment for children with disabling conditions

Fractures are a frequent source of morbidity in children with disabling conditions. The assessment of bone density in this population is challenging, because densitometry is influenced by dynamic forces affecting the growing skeleton and may be further confounded by positioning difficulties and surgical hardware. First-line treatment for pediatric osteoporosis involves conservative measures, including optimizing the management of underlying conditions, maintaining appropriate calcium and vitamin D intake, encouraging weight-bearing physical activity, and monitoring measurements of bone mineral density. Bisphosphonates are a class of medications that increase bone mineral density by inhibiting bone resorption. Although bisphosphonates are commonly prescribed for treatment of adult osteoporosis, their use in pediatric patients is controversial because of the lack of long-term safety and efficacy data.

Spina bifida grown up

The majority of people with spina bifida in the United States are now older than 18 years of age. Health care delivery for adults with this condition should include routine surveillance for common conditions such as hypertension, hyperlipidemia and cancer. It should also address spina bifida-related complications such as pressure sores, lymphedema, sexual dysfunction and infertility, and hydrocephalus, as well as chiari-related symptoms such as sleep apnea and urologic and renal functioning. Almost all adults with spina bifida benefit from regular followup with specialists in urology, neurosurgery and physiatry. Health care providers for adults with spina bifida should recognize the impact of executive dysfunction and nonverbal learning disability on self management, independent living, and employment in adults with spina bifida.

Epidemiology of neurologically disabling disorders

Neurological disorders place a considerable burden upon individuals, their families, and society. Some like stroke are common, while others like amyotrophic lateral sclerosis are much rarer. Some conditions such as multiple sclerosis are reported to vary by latitude, while others such as traumatic brain injury can vary considerably by locality. Depending upon the nature of the lesion, and factors such as time since onset, the consequences to the individual may also vary considerably, not just among different disorders, but within a given disorder. Consequently the patterns of disease incidence, its prevalence, and its consequences are complex and may vary not just because of the condition itself, but also because, for example, case ascertainment may vary from study to study. The cumulative annual incidence of disabling neurological disorders is likely to exceed 1000 per 100000, or 1% of the population. The incidence is characterized by significant variation, which is mediated by genetic, geographical, demographic, and environmental factors. While useful comparisons can be made through standardization techniques, planning for local services should be based upon local epidemiology, whenever available.

Osteoporosis in paediatric patients with spina bifida

The prevalence and morbidity associated with osteoporosis and fractures in patients with spina bifida (SB) highlight the importance of osteoporosis prevention and treatment in early childhood; however, the issue has received little attention. The method for the selection of appropriate patients for drug treatment has not been clarified.

OBJECTIVE

To review the literature concerning fracture risks and low bone density in paediatric patients with SB. We looked for studies describing state-of-the-art treatments and for prevention of secondary osteoporosis.

METHODS

Articles were identified through a search in the electronic database (PUBMED) supplemented with reviews of the reference lists of selected papers. The main outcome measures were incidence of fractures and risk factors for fracture, an association between bone mineral density (BMD) and occurrence of fracture, risk factors of low BMD, and effects of pharmacological and non-pharmacological treatments on BMD and on the incidence of fractures. We considered as a secondary outcome the occurrence of fractures in relation to the mechanism of injury.

RESULTS

Results indicated that patients with SB are at increased risk for fractures and low BMD. Risk factors that may predispose patients to fractures include higher levels of neurological involvement, non-ambulatory status, physical inactivity, hypercalciuria, higher body fat levels, contractures, and a previous spontaneous fracture. Limitations were observed in the number and quality of studies concerning osteoporosis prevention and treatment in paediatric patients with SB. The safety and efficiency of drugs to treat osteoporosis in adults have not been evaluated satisfactorily in children with SB.

Tissue stiffness induced by prolonged immobilization of the rat knee joint and relevance of AGEs (pentosidine)

Joints, connective tissues consisting of extracellular matrix (ECM) with few blood vessels, transfer tension to the skeleton in response to environmental demand. Therefore, joint immobilization decreases active and passive mechanical stress, resulting in increased joint stiffness and tissue degeneration; however, the cause of joint stiffness is obscure. Using a rat knee immobilization model, we examined the relationship between range of motion (ROM) and cell numbers and ECM cross-links by accumulation of advanced glycation end products, pentosidine, in the posterior joint capsule of immobilized joints during 16 weeks of immobilization. The left knee joint was immobilized by internal fixation and compared with the non-immobilized right leg. As early as 2 weeks of immobilization, joint ROM and torque significantly decreased and in parallel, disordered alignment of collagen fiber bundles significantly increased, compared with non-immobilized joints. Those changes continued until 16 weeks of immobilization. Significant increases in pentosidine-positive areas after 8 weeks and significantly decreased cell numbers after 16 weeks of immobilization were also observed compared to the contralateral side. A significant negative correlation between tissue stiffness measured by restriction of ROM and accumulation of pentosidine was observed. This study is the first to show that immobilization of knee joints induces articular contracture associated with sequential changes of ECM alignment, influencing ROM and later pentosidine accumulation and decreased cell numbers during the 16-week immobilization period. Pentosidine appears to be an indicator toward a chronic tissue stiffness leading to decreased cell number rather than a cause of ROM restriction induced by joint immobilization.

Fractures in myelomeningocele

Background

In 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 methods

Between 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.

Results

During 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.

Conclusions

Patients 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.

Prevalence of spina bifida among children and adolescents in 10 regions in the United States

OBJECTIVE

The goal was to estimate the number of children and adolescents, 0 to 19 years of age, living with spina bifida (SB) in the United States.

METHODS

A retrospective study was conducted by using population-based, birth defect surveillance data from 10 US regions, with vital status ascertainment. Birth defect surveillance data were obtained from Arkansas, Georgia (5 central counties of metropolitan Atlanta), California (11 counties), Colorado, Iowa, New York (New York City excluded), North Carolina, Oklahoma, Texas, and Utah. We estimated the numbers of children 0 to 19 years of age who were living with SB in the 10 US regions in 2002, according to age group, race/ethnicity, and gender, and examined a long-term trend in the prevalence of SB among children 0 to 11 years of age in 1991-2002.

RESULTS

The overall prevalence of SB among children and adolescents 0 to 19 years of age in the study regions was 3.1 cases per 10,000 in 2002. The prevalence of SB among children was lower among male and non-Hispanic black children.

CONCLUSIONS

The prevalence estimates of SB among children and adolescents varied according to region, race/ethnicity, and gender, which suggests possible variations in prevalence at birth and/or inequities in survival rates. Additional studies are warranted to elucidate the reasons for these variations and to derive prevalence estimates of SB among adults.

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

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. Forty-five 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 [corrected] 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.

Neuro-epiphyseal injury around the ankle: a case report

An epiphyseal injury without obvious trauma is a diagnostic dilemma; in neurologically impaired children, the lack of sensation and repetitive trauma can lead to neuropathic injuries of the physeal plate, with bizarre X-ray changes; the problem is compounded by lack of awareness in the average orthopaedist, leading to treatment delays and unnecessary procedures like biopsy, or even surgery for osteomyelitis or malignancy, with increased morbidity and disability. We report a 12-year male child with myelomeningocele and neurological deficit; he presented with painless swelling and redness of left leg and sensory-motor deficit below the knee joints. X-rays showed distal tibial epiphysis plate widening and irregularity. A diagnosis of neuropathic epiphyseal plate injury was considered; the clinico-radiological picture only resolved after rigid immobilization in below knee POP casts and abstinence of weight bearing. Lesser changes were noted in the opposite side also. The injured physis displaced somewhat posteromedially over 8 months, but ultimately fused; contra-lateral changes subsided with partial physeal fusion. The objective of reporting this unusual case is to increase the awareness levels, and to report the bizarre radiological changes. Management involves non-weight bearing immobilization; diagnostic delays lead to more reactive changes with higher incidence of subsequent physeal closure.