**3. Pathologic fractures**

Due to the lack of ambulation, physical exercise and axial bone load spina bifida patients can present with osteoporosis and osteoporosis induced fractures [10]. The

#### **Figure 1.**

*Right distal femur fracture in a myelomeningocele patient without an obvious traumatic mechanism (A) and radiographic images of post-reduction and casting (B).*

**93**

**Figure 2.**

*Myelomeningocele patient with marked lumbar kyphosis.*

*Orthopedic Approach to Spina Bifida*

aged as appropriate [16].

**4. Spine care**

*DOI: http://dx.doi.org/10.5772/intechopen.94901*

fractures usually occur below the neurological level of the defect and the incidence ranges from 11 to 30% [11]. The fracture mechanism is usually pathologic, these fractures usually being caused by minor trauma or even spontaneously [12]. Since many of these patients may have a fractured bone without an obvious trauma mechanism it can be difficult to diagnose these fractures. Patients usually present with a swollen, warm extremity with associated redness, and this should prompt obtaining a radiographic imaging study [13]. The caring orthopedist should be aware not to confuse these symptoms with an infection. The fractures are common the higher the level of the neural defect, in the distal femur or around the hip in patients from 3 to 7 years old (**Figure 1**) [14]. Treatment is usually non-surgical and involves immobilization in a cast. Prolonged immobilization in the cast should be minimized since this also will make osteopenia worse [15]. Patients should be assessed for bone density with dual-energy X-ray absorptiometry (DEXA scan) exams and calcium and vitamin D levels should be assessed and replaced if necessary, by the pediatrician. Weight bearing and physical exercise should be encour-

Besides the posterior element defect in the spine, spina bifida patients also present with severe congenital deformity and contractures of the spine. These deformities can pose a restriction to everyday activities as well as pulmonary function [17]. A third of the patients will have scoliosis, which is usually of an early onset and has a tendency to progress and cause pelvic obliquity [18]. Scoliosis has different causes in these patients such as muscle imbalance or primary malformations like hemivertebra and vertebral fusions. Kyphosis may also be present in approximately 15% of the patients (**Figure 2**). Is usually progressive and mostly located in the lumbar region [19]. The deformity can be so severe to cause skin breakdown at the level of the deformity (**Figure 3**). Surgery is necessary to correct the deformity and is not free of complications in these patients. Usually there is no role for bracing spine deformity in these patients and the skin insensitivity can predispose to skin ulcers and infection. Surgical correction is indicated in patients with progressing curves who are good candidates for surgery. Posterior fixation is the most common procedure performed but other options such as an anterior fusion or combined ones are used as well when appropriate. In patients with pelvic obliquity the fixation should be extended until the pelvis level, this is particularly important in non-ambulatory patients (**Figure 4**) [20]. Surgery can be associated with higher risks of infection, anesthesia complications, bleeding, non-union, hardware failure, loss

#### *Orthopedic Approach to Spina Bifida DOI: http://dx.doi.org/10.5772/intechopen.94901*

fractures usually occur below the neurological level of the defect and the incidence ranges from 11 to 30% [11]. The fracture mechanism is usually pathologic, these fractures usually being caused by minor trauma or even spontaneously [12]. Since many of these patients may have a fractured bone without an obvious trauma mechanism it can be difficult to diagnose these fractures. Patients usually present with a swollen, warm extremity with associated redness, and this should prompt obtaining a radiographic imaging study [13]. The caring orthopedist should be aware not to confuse these symptoms with an infection. The fractures are common the higher the level of the neural defect, in the distal femur or around the hip in patients from 3 to 7 years old (**Figure 1**) [14]. Treatment is usually non-surgical and involves immobilization in a cast. Prolonged immobilization in the cast should be minimized since this also will make osteopenia worse [15]. Patients should be assessed for bone density with dual-energy X-ray absorptiometry (DEXA scan) exams and calcium and vitamin D levels should be assessed and replaced if necessary, by the pediatrician. Weight bearing and physical exercise should be encouraged as appropriate [16].
