Treatment of femur fractures in children with cerebral palsy

Child Fractures: Are We Getting More Surgical?

Historically, surgeries on the immature skeleton were reserved for open or articular fractures. In recent years, the improvement in the quality and safety of anesthesia, new imaging equipment, implants designed especially for pediatric fractures, associated with the possibility of shorter hospitalization time and rapid return to social life has demonstrated a new tendency to evaluate and treat fractures in children. The purpose of this update article is to answer the following questions: (1) Are we really turning more surgical in addressing fractures in children? (2) If this is true, is this surgical conduct based on scientific evidence? In fact, in recent decades, the medical literature demonstrates articles that support better evolution of fractures in children with surgical treatment. In the upper limbs, this is very evident in the systematization of the reduction and percutaneous fixation of supracondylar fractures of the humerus and fractures of the forearm bones. In the lower limbs, the same occurs with diaphyseal fractures of the femur and tibia. However, there are gaps in the literature. The available published studies show low scientific evidence. Thus, it can be inferred that, even though the surgical approach is more present, the treatment of pediatric fractures should always be individualized and conducted according to the knowledge and experience of the professional physician, taking into account the presence of technological resources available for the care of the small patient. All possibilities, non-surgical and/or surgical, should be included, always instituting actions based on science and in agreement with the family's wishes.

5-year fracture risk among children with cerebral palsy

BACKGROUND

Epidemiologic evidence documenting fracture risk as children with cerebral palsy (CP) age throughout growth is lacking to inform on when to implement fracture prevention strategies. The objective was to characterize the 5-year risk of fractures by each year of age among <1-13 year olds with CP and effects by patient-level factors.

METHODS

This retrospective cohort study used commercial administrative claims from 01/01/2001 to 12/31/2018 from children <1-13 years old with ≥5 years of insurance enrollment. Fractures were examined during the 5-year follow-up. For the CP cohort, the association between 5-year fracture rate and patient-level factors was assessed using Cox regression.

RESULTS

Children with (n = 5559) vs. without (n = 2.3 million) CP had a higher 5-year fracture risk at the vertebral column, hip, and lower extremities at almost each year of age, but lower 5-year fracture risk at the upper extremities after 6 years old (all P < 0.05). Among children with CP, the 5-year fracture rate was elevated for co-occurring neurological conditions and non-ambulatory status at the vertebral column, hip, and lower extremities (hazard ratio [HR] range, 1.44-2.39), and higher for males at the upper extremities (HR = 1.29) (all P < 0.05).

CONCLUSIONS

This study provides novel epidemiologic evidence of 5-year fracture risk for each year of age for children with CP.

IMPACT

This study provides novel epidemiologic evidence of 5-year fracture risk for each year of age across important developmental stages for children with vs. without cerebral palsy (CP). Children with vs. without CP were more likely to fracture at the vertebral column, hip, lower extremities, and humerus and less likely to fracture at the forearm and hands. The age-related 5-year fracture risk was associated with clinically relevant patient-level factors, but in different ways by fracture region. Study findings may be used to enhance clinical detection of at-risk children and strategize when to implement fracture prevention efforts for children with CP.

Closed displaced femur fractures in children with nonambulatory cerebral palsy

Femoral fractures in children withcerebral palsy (CP) represent a frequent medical problem, and treatment represents a challenge. The purpose of this study was to review the closed displaced femoral fractures in our population of nonambulatory children with CP to compare the results of nonoperative and operative treatment modalities to improve the care of these children. From 2006 to 2020, children with nonambulatory CP were selected with inclusion criteria of displaced femoral fracture and were divided into nonoperative and operative groups. Forty-four children met the inclusion criteria. The nonoperative group included 23 children and the operative group included 21 children. Mechanism of injury was unknown in 48% of the fractures. Fourteen (25%) fractures occurred after a femoral plate fixation during a reconstructive hip surgery, and 38 (86%) children had osteopenia. Our results reveal a high prevalence of osteopenia, low-energy trauma, malunion in nonoperative treatment, and peri-implant fractures. Suspicion of child abuse should be considered when the fracture has an unclear mechanism of the injury. Removal of proximal femoral implants may be considered to prevent peri-implant fractures. Femoral fractures should preferably be treated nonoperatively. Operative treatment should be considered for diaphyseal fractures in children capable of standing transfers, larger children, children with more severe spasticity or movement disorder or those who have suffered a high-energy fracture. Due to the high prevalence of proximal fractures in the presence of hardware, operative treatment is usually required for these fractures. In contrast, distal fractures are adequately managed nonoperatively.

Femoral shaft fractures in children with non-ambulatory neuromuscular disorders can be effectively treated using flexible intramedullary nails

PURPOSE

There is little information in the literature regarding flexible intramedullary nails (FIN) for treating femur fractures in children with neuromuscular disorders. The purpose of this study is to investigate the outcomes of FIN for femoral shaft fractures in non-ambulatory children with neuromuscular disorders.

METHODS

A retrospective review was conducted on patients with femur fractures at a paediatric hospital between 2004 and 2018. Inclusion criteria were femoral shaft fracture treated with FIN. Outcomes were compared between patients with neuromuscular disorders (NM group) and a control group of those without neuromuscular disorders.

RESULTS

A total of 37 patients with 37 femoral shaft fractures were studied (12 patients in the NM group and 25 in the control group). All NM group patients were non-ambulatory at baseline. Fractures were length stable in all 25 patients in the control group and in 2/12 (17%) patients in the NM group. All fractures healed in both groups. Three complications (all nail migrations) requiring reoperation before fracture union occurred in the NM group, yielding a major complication rate of 25% (3/12) in the NM group versus 0% (0/25) in controls (p = 0.03). Angular deformity occurred in 5/12 (42%) NM group patients and 1/25 (4%) control group patient (p = 0.009); none required reoperation.

CONCLUSION

Femur fractures in non-ambulatory children with neuromuscular disorders can be successfully treated with FIN. Angular deformities are common in this population, but had no functional impact in the non-ambulatory NM group patients. Surgeons must also be vigilant for implant prominence and skin breakdown in these patients.

LEVEL OF EVIDENCE

III.

Elevated fracture risk for adults with neurodevelopmental disabilities

BACKGROUND

Fracture is a high-burden condition that accelerates unhealthful aging and represents a considerable economic burden. Adults with neurodevelopmental disabilities (NDDs) may be susceptible for fracture at younger ages compared to adults without NDDs; and yet, very little is known about the burden of fracture for these underserved populations. The purpose of this study was to determine the sex-stratified prevalence of all-cause fracture among adults with NDDs, as compared to adults without NDDs, and if comorbidity of NDDs is associated with greater risk of fracture.

METHODS

Data from 2016 were extracted from Optum Clinformatics® Data Mart (private insurance) and a random 20% sample from Medicare fee-for-service (public insurance). ICD-10-CM diagnosis codes were used to identify adults with NDDs, including intellectual disabilities, autism spectrum disorders, and cerebral palsy. Age-standardized prevalence of any fracture and fracture by anatomical location was compared between adults with and without NDDs, and then for adults with 1 NDD vs. 2 and 3 NDDs.

RESULTS

Adults with intellectual disabilities (n=69,456), autism spectrum disorders (n=21,844), and cerebral palsy (n=29,255) had a higher prevalence of any fracture compared to adults without NDDs (n=8.7 million). For women, it was 8.3%, 8.1%, and 8.5% vs. 3.5%, respectively. For men, it was 6.6%, 5.9%, and 6.7% vs. 3.0%, respectively. Women with NDDs had a higher prevalence of fracture of the head/neck, thoracic, lumbar/pelvis, upper extremities, and lower extremities compared to women without NDDs. A similar pattern was observed for men, except for no difference for lumbar/pelvis for all NDDs and thoracic for autism spectrum disorders. For women and men, increasing comorbidity of NDDs was associated with a higher prevalence of any fracture: 1 NDD (women, 7.7%; men, 5.7%); 2 NDDs (women, 9.4%; men, 7.2%); all 3 NDDs (women, 11.3%; men, 13.7%).

CONCLUSIONS

Study findings suggest that adults with NDDs have an elevated prevalence of fracture compared to adults without NDDs, with the fracture risk being higher with greater numbers of comorbid NDD conditions for most anatomical locations. Our study findings indicate a need for earlier screening and preventive services for musculoskeletal frailty for adults with NDDs.

Adults with Cerebral Palsy have Higher Prevalence of Fracture Compared with Adults Without Cerebral Palsy Independent of Osteoporosis and Cardiometabolic Diseases

Individuals with cerebral palsy (CP) have an increased risk of fracture throughout their lifespan based on an underdeveloped musculoskeletal system, excess body fat, diminished mechanical loading, and early development of noncommunicable diseases. However, the epidemiology of fracture among adults with CP is unknown. The purpose of this cross-sectional study was to determine the prevalence of fracture among a large sample of privately insured adults with CP, as compared with adults without CP. Data were from the Optum Clinformatics Data Mart (Eden Prairie, MN, USA), a deidentified nationwide claims database of beneficiaries from a single private payer. Diagnostic codes were used to identify 18- to 64-year-old beneficiaries with and without CP and any fracture that consisted of osteoporotic pathological fracture as well as any type of fracture of the head/neck, thoracic, lumbar/pelvic, upper extremity, and lower extremity regions. The prevalence of any fracture was compared between adults with (n = 5,555) and without (n = 5.5 million) CP. Multivariable logistic regression was performed with all-cause fracture as the outcome and CP group as the primary exposure. Adults with CP had a higher prevalence of all-cause fracture (6.3% and 2.7%, respectively) and fracture of the head/neck, thoracic, lumbar/pelvic, upper extremity, and lower extremity regions compared with adults without CP (all p < 0.01). After adjusting for sociodemographic and socioeconomic variables, adults with CP had higher odds of all-cause fracture compared with adults without CP (OR 2.5; 95% CI, 2.2 to 2.7). After further adjusting for cardiometabolic diseases, adults with CP had higher odds of all-cause fracture compared with adults without CP (OR 2.2; 95% CI, 2.0 to 2.5). After further adjusting for osteoporosis, adults with CP still had higher odds of all-cause fracture compared with adults without CP (OR 2.0; 95% CI, 1.8 to 2.2). These findings suggest that young and middle-aged adults with CP have an elevated prevalence of all-cause fracture compared with adults without CP, which was present even after accounting for cardiometabolic diseases and osteoporosis. © 2019 American Society for Bone and Mineral Research.

Age trajectories of musculoskeletal morbidities in adults with cerebral palsy

BACKGROUND

Individuals with cerebral palsy (CP) are at an increased risk for age-related morbidities due to functional impairments, maladapted growth, and altered body composition. While musculoskeletal (MSK) deficits are present in children, little is understood about MSK morbidity throughout the lifespan in those with CP. The purpose of this study was to examine the age-related trajectories of MSK morbidity and multimorbidity throughout adulthood in those with CP.

METHODS

A clinic-based sample of adults with CP (n = 1395; ≥18 years) was examined to determine prevalence of MSK morbidities at the University of Michigan Medical Center. Logistic regression was used to determine the effects of age on individual MSK morbidities and multimorbidity (i.e., ≥2 morbidities) after adjusting for sex, race, weight, and smoking.

RESULTS

With the 18-30 year age group as the reference, the adjusted odds of osteopenia was lower in the 41-50 and >50 year age groups, the odds of osteoporosis and rheumatoid arthritis was higher in 41-50 and >50 year age groups, and the odds of osteoarthritis was higher in 31-40, 41-50, and >50 year age groups. The adjusted odds of MSK multimorbidity increased substantially with increasing age for 31-40 year olds (OR: 1.919; 95% CI 1.05-3.52), 41-50 year olds (OR: 4.30; 95% CI 2.40-7.69), and >50 year olds (OR: 6.05; 95% CI 3.56-10.27).

CONCLUSIONS

Adults with CP are at high risk for MSK morbidities across all ages. Future studies are needed to examine the global aging trajectories of MSK health among adults with CP. Study findings highlight the importance of maximizing MSK accretion, and developing programs to assist individuals with CP and their caregivers to maintain MSK mass and function throughout the lifespan.

A qualitative investigation of recovery after femoral fracture in Rett syndrome

BACKGROUND

Children with severe disability often develop osteoporosis and have an increased risk of fracture. In Rett syndrome, the prevalence of fracture is four times greater than in the general population, and the femur is commonly affected. This study used qualitative methods to investigate the regaining of mobility within 12 months following femoral fracture in Rett syndrome and parent caregiver experiences.

METHODS

Caregivers (n = 14) of cases registered with the Australian Rett Syndrome Database with a daughter with Rett syndrome were recruited if their daughter sustained a femoral fracture between 2009 and 2014. Median (interquartile range) age at fracture was 11 years and 4 months (8 years and 8 months to 22 years and 3 months). Qualitative methods were used to investigate parent/caregiver experiences and their daughter's recovery following fracture. Themes in the interview data were identified with thematic analysis.

RESULTS

Operative management was chosen for those walking independently and non-operative management for most of the remaining. All who walked independently and one of the four who required assistance recovered pre-operative walking skills within 6 months. Themes identified by caregivers related to the complexities of pain recognition, the caregiver emotional journey and later rebuilding of relationships with service providers.

CONCLUSIONS

Those who walked with assistance were vulnerable to loss of this skill. Difficulties in pain recognition increased time to diagnose fracture, and the acute episode was associated with heightened caregiver stress. Service providers can use family-centred practice models to support the strengthening of family functioning following this acute event that is surprisingly common in those with severe disability.

Treatment outcomes after insufficiency femoral diaphyseal fractures in nonambulatory children

We retrospectively reviewed the treatment and outcomes of diaphyseal femur fractures in a cohort of nonambulatory children. There were 30 patients (38 fractures) reviewed [average age of 10.1 years (range: 1.8-17.8)]. Fractures were treated with locked plate/screw fixation (n=18), with a complication rate of 24% (9/38). Patients with elastic stable intramedullary nailing experienced the highest complication rate (5/7, 71%) compared with plate/screw fixation (2/18, 11%) (P=0.01) and underwent greater subsequent procedures (n=5, 63%). Surgeons should consider locked plate and screw fixation as their first treatment choice in this challenging patient population.

LEVEL OF EVIDENCE

III, therapeutic study; retrospective comparative study.

Fixator-augmented flexible intramedullary nailing for osteopenic femoral shaft fractures in children

Children with underlying metabolic bone diseases, such as osteogenesis imperfecta and spastic cerebral palsy, pose a challenge in the treatment of femoral shaft fractures. We performed flexible intramedullary nailing with supplemental monolateral external fixation in a subgroup of such patients. The external fixator assists in controlling angulation and rotation at the fracture site, and avoids the need for supplemental casting with its associated problems such as skin breakdown and difficulty with personal hygiene. We describe the surgical technique, pitfalls, and outcomes in a series of four patients with underlying osteopenia treated with external fixator-augmented flexible nailing for femoral shaft fractures.

Use of a proximal humeral plate for a paediatric peri-prosthetic femoral fracture

In this case an 18-year-old female with cerebral palsy sustained a peri-prosthetic femoral fracture adjacent to a blade plate previously inserted for a femoral varus osteotomy. The injury was treated using a long proximal humeral locking plate. The existing blade plate was removed. The fracture was reduced and held, and a 10-hole PHILOS™ plate applied with near anatomical reduction. There were no post-operative complications. Radiographic union was confirmed at 11 months. To our knowledge, this is the first reported use of a PHILOS™ plate in the management of a femoral peri-prosthetic fracture and successfully demonstrated a straightforward method for revision fixation.