Orthopedic Care

Pressure sores occur in 85-95% of children with myelomeningocele before young adulthood. Recurrent sores can lead to prolonged morbidity and functional disability. Healing can occur if the areas of pressure are eliminated. Plastic surgery may be necessary in severe cases and may involve orthopedic correction of underlying postural abnormalities.

The sites and causes of skin breakdown vary by age and lesion level. Skin breakdown on the lower limb occurs in 30-50% of cases in all lesion-level groups.

“The most common areas of breakdown in the thoracic-level group are the area below the genitals and above the apex of the spinal curve. Older children may have higher risk of skin breakdown because of increased pressure of a larger body weight gain, asymmetric weight bearing from acquired musculoskeletal deformities, and lower limb vascular insufficiency or venous stasis” (Hunt, 2003, p. 1365).

Other frequent causes more prevalent in the younger child include casts or orthotic devices, skin breakdown from urine and stool soiling, friction, shear, and burns.

Bone mineral density is decreased in patients with myelomeningocele. Markers of bone re absorption were found more frequently in both limited ambulatory and non-ambulatory than in children who ambulated regularly. Children with myelomeningocele are at higher risk of lower extremity fractures. Reduced muscle activity in the paralyzed limb and decreased weight-bearing forces result in decreased bone mass. “In addition, many fractures occur after orthopedic interventions, especially after procedures associated with cast immobilization. Fractures in myelomeningocele tend to heal quickly, and excessive callus formation often is seen” (Brown, 2001, p. 51). Relative immobilization (i.e., short casting times and early weight bearing) is the standard recommendation for healing after fractures. The goal is maintaining functional alignment and rotation without compromising the patient's ability to stand and ambulate.

Obesity is prevalent in children with myelomeningocele, especially those with high-lumbar and thoracic-level lesions because of reduced capacity for caloric expenditure. The decreased muscle mass of the lower body musculature results in a lower basal metabolic rate. In addition, activity levels generally are lower than in unaffected children, both as a direct result of lesion-related mobility deficits and as an indirect result of decreased opportunities for disabled children to participate in physical play. Obesity can exert negative impact on self-image and further perpetuate a cycle of inactivity and overeating. Because of their decreased linear limb growth and spine growth, patients with myelomeningocele should be monitored for weight using arm span measurements, as opposed to ratios of height versus weight (Johnson, 2004).

The number of surgeries and an exposure to latex are the most important risk factors for development of an allergy in children with myelomeningocele. Establishment of a latex-free environment for surgery has resulted in a decrease in sensitization of these patients to latex (Frankland, 1999).