Хірургія дитячого віку (Dec 2021)
The problem of osteoporotic fractures of the femur in children with cerebral palsy
Abstract
The relevance of the topic is dictated by the high frequency of osteopenia and osteoporosis in children with cerebral palsy (CP) with IV and V levels according to the GMFCS and the corresponding number of cases of osteoporotic fractures in such patients. During the treatment of such children there are a number of significant problems: reduced mechanical properties and osteoporotic changes in bone tissue, there are pronounced contractures of adjacent joints, inability to move independently, increased risk of bedsores, concomitant neurological pathology and more. This issue is covered in a number of foreign publications and the search for solutions continues. Purpose – sharpen the attention of doctors, staff of rehabilitation centers, parents at increased risk of osteoporotic fractures in patients with CP. To determine the strategy of treatment of such fractures and features of further management of patients of this category. Materials and methods. During the period from 2014 to 2021, 11 patients with CP with osteoporotic fractures of the femur (12 fractures, 1 child with bilateral injuries) were treated in the Chernihiv Regional Children’s Hospital. Rehabilitation and rehabilitation therapy was conducted at the Regional Center for Comprehensive Rehabilitation of Children with Disabilities «Renaissance». Age distribution: from 3 years to 17 years, with the exception of 1 adult patient 40 years (body weight 30 kg). By form of CP: spastic paresis in 9, flaccid paresis in 2 patients. By type of CP: tetraparesis in 9, diplegia in 2 patients. According to the level of GMFCS: III level – 2, IV level – 6, V level – 3 patients. Radiography was performed in 2 projections according to standard methods during fracture diagnosis, intraoperatively, and in the process of consolidation control. Results. All patients had neurological disorders, moved with support or in a wheelchair, had contractures of adjacent joints, according to the pattern, type and form of cerebral palsy, had difficulty with proper nutrition, most had comorbidities. Fractures of the femur occurred from a minor injury (falling from a minor height), or the application of minor force (in the process of exercise, massage or development of movements). Traumagenesis: during the care and development of movements by parents – 3, fall in the home – 2, during an epileptic seizure – 2, during exercise therapy in medical institutions – 4. It should be emphasized that in the case of spastic subluxation and hip dislocation, as well as the available history of reconstructive interventions on the hip joint dramatically increase the possibility of osteoporotic fractures. Clinical manifestations are often obscured: in most cases, children are non-contact (mental retardation of various degrees causes a negative psychological reaction – «white coat» syndrome), have altered pain threshold, traumatic tissue edema and hematomas are not expressed, pre-existing spastic contractures and deformities injured limb. Treated conservatively (plaster fixation) – 6 patients, surgical treatment was performed in 5 children. In the case of conservative treatment, plaster fixation was performed according to the general principles, but taking into account the contractures of the joints that were before the traumatic injury. For example, an oppressive bandage was applied with flexion in the knee joint (in the case of flexion contracture) and/or flexion in the ankle joint (in the presence of an equinus foot installation). Preference was given to polymeric materials, which improved the possibility of hygienic care, air permeability, significantly reduced the weight of the immobilization bandage. In the case of surgical treatment, minimally invasive methods were preferred: ESIN, which allowed to stabilize the fracture, and to avoid long-term fixation in a plaster cast. We draw the attention of orthopedic traumatologists to possible technical difficulties during surgery, which are associated with reduced density and strength of bone tissue! According to the indications (pronounced flexion-drive contractures of the thighs), tenomyotomies of the thigh adductors and partial tenotomy of the illiopsoas muscle were performed. In all cases, consolidation of femoral fractures was achieved in standard time. Conclusions. Patients with CP who are unable to move independently have an increased risk of fractures of the femur in connection with which there is a need for preventive antiosteoporotic measures (verticalization of such patients in special devices, medical treatment (calcium and vitamin D), use vibration, etc.). It is necessary to sharpen the attention of parents, staff of rehabilitation centers, doctors on this issue and use non-aggressive methods in the process of rehabilitation. Orthopedic traumatologists should apply a special strategy for the treatment and management of children with CP with osteoporotic fractures of the femur. The research was carried out in accordance with the principles of the Helsinki declaration. The study protocol was approved by the Local ethics committee of all participating institutions. The informed consent of the patient was obtained for conducting the studies. No conflict of interest was declared by the author.
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