Treatment of femur fractures in children with cerebral palsy

Abstract

Purpose Children with cerebral palsy may have low bone density stemming from various etiologies and are, thereby, at risk for fractures. The treatment of femur fractures in children with cerebral palsy may need to be tailored to address the management of spastic muscle tone and multiple medical co-morbidities. Methods Our study is a retrospective review that evaluates the treatment of 47 femur fractures in children with cerebral palsy in both ambulatory and non-ambulatory patients.Results Thirty-two fractures in non-ambulators were treated non-operatively, 11 of which resulted in malunions and five developed pressure sores. Six fractures in nonambulators were treated operatively, one of which resulted in a malunion. In ambulators, five fractures were treated non-operatively; one of these fractures lost reduction after 2 weeks and required surgical intervention. One of four fractures in ambulators treated operatively developed a malunion. Conclusion Our study results suggest that femur fractures in children with cerebral palsy can be treated non-operatively; however, because of the high risk of malunion in this patient population, fracture alignment needs to be followed closely during healing. Careful attention during casting is necessary to prevent pressure sores. Strong consideration should be given to initial operative treatment in ambulatory patients in order to preserve function.

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

“…Children with CP are therefore predisposed to an inadequate development of muscle and bone during growth, with the underdevelopment of the musculoskeletal system apparent prior to their 2 nd birthday . The result is a structurally weak musculoskeletal system, which helps to explain the heightened susceptibility for acquiring low‐energy fractures among this pediatric population . Importantly, as children with CP transition into and throughout adulthood, there is a further loss of ambulatory ability with resultant decrease in weight‐bearing, which increases fracture risk throughout the lifespan.…”

Complications in the surgical management of femur fractures in children with non-ambulatory cerebral palsy

“…One resulted in a malunion, one developed a cast-related pressure sore, one developed pneumonia and one developed a bacteraemia giving an overall complication rate of 67%. 7 Treating femur fractures in nonambulatory CP children with surgery is associated with a much higher complication rate and can be extremely challenging, as seen in our patient. Our initial primary goal with this patient was to alleviate her pain and allow her to be mobilised into a chair as soon as possible following the initial fracture.…”

“…1,3,7 Malunion in these patients is generally well tolerated as long as it does not interfere with perineal care and sitting balance. 1,5 Conservative management in severe cerebral palsy has been described with good outcomes.…”

“…1 Leet et al also showed that fractures in non-ambulatory patients with CP can be treated conservatively. 7 Of 32 femur fractures treated conservatively, one-third healed in a malunion and five resulted in cast-related pressure sores. They emphasised that special attention should be paid to prevent high rates of significant malunion as shown in the article by McIvor et al Significant malunion was defined as resulting in discomfort, seating or caring difficulties.…”

“…The risk of non-union in this population was negligible in both studies. 1,7 Conservative treatment should be regarded as the gold standard but careful attention must be paid to addressing causes for osteoporosis, controlling epilepsy and preventing complications, specifically pressure sores (either related to cast or bed immobility), malunion and pneumonia (either related to immobility or aspiration).…”