Spina bifida hip

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The spina bifida hip is a complex problem in pediatric orthopedics . The segmental height of the myelomeningocele gives rise to various imbalances in the hip muscles. You decide on the child's ability to stand and walk.

problem

Segmental innervation of the hip muscle groups

The orthopedic treatment of children with spina bifida aims to enable them to walk with as few aids as possible. The most common, most important and most difficult problems arise in the hip joint .

More than half of the children show a hip dislocation at birth . Flexion, external twisting, and splay contractures develop due to the muscular imbalance in most children. The contractures can be so severe that the children cannot even sit in individual pans. Regular sitting with pelvic inclination and lumbar hyperkyphosis or lordosis in turn leads to permanent hip and spinal deformities. Unequal hip positions are particularly unfavorable in spastic contractures. You can dislocate the adduction side and tilt the sacrum , which makes it difficult to maintain an upright posture. This is why it is important to maintain or restore mobile hip joints even in wheelchair patients.

The overall functional disability by a myelomeningocele the result of position-induced deformities and out of the paralysis induced imbalance of muscles. The height of the spinal malformation is decisive .

Thoracic myeloceles

Hip dislocation in thoracic MMC

The paralysis is distal to Th 12. With its apparent muscular balance, reflex activity in the spinal segments distal to the myelocele can cause hip dislocation. In addition, there is a risk of the dreaded “frog pose”, i. H. the flexion, splay and external twist contracture of the hip joints.

Upper lumbar myeloceles

The paralysis is distal to L2. When the extensors and abductors are completely paralyzed, the flexors and adductors are partially innervated. A partial muscular imbalance with a subluxation of the hip results. About a third of these patients can walk without orthoses . Due to the reflex activity, clubfoot and genu valgum are common complications of these myeloceles . Non-luxated hips can be better adjusted through repositioning and acetabular surgery.

Lower lumbar myeloceles

The paralysis is distal to L 4. The flexors and adductors are largely intact, but the extensors and abductors are not innervated. This pronounced muscular imbalance leads to hip dislocation. In order to adjust and maintain it, a muscular balance must be established. In addition to corrective osteotomies and acetabuloplasties, the main considerations are the severing of the tendons of contracting muscles (Menelaus) and the transfer of the psoas major muscle (Sharrard).

Sacral myeloceles

The paralysis is distal to L 5. The muscular equilibrium levels off again. In infancy, it is important to carefully monitor whether a hip dislocation develops. Sometimes conservative dysplasia treatment with spreader pants is sufficient . Almost all patients can later walk without apparatus. With the frequent deformities of the feet, you need orthopedic footwear.

treatment

The orthopedic treatment of spina bifida children consists of physiotherapy , positioning aids, standing exercises and walking training. Operations are designed to prevent or correct the dislocation and flexion contractures. Of course, unfavorable accompanying circumstances must be taken into account - mental retardation, spasticity , hydrocephalus , spinal deformities and reflex activity.

literature

  • JH Beaty, ST Canale: Current concepts review: orthopedic aspects of myelomeningocele. In: The Journal of Bone & Joint Surgery . [Am] 72-A, 1990, pp. 626-630.
  • German Medical Association (Scientific Advisory Board): Recommendations for the care of children with spina bifida. In: Deutsches Ärzteblatt. 74/26, 1977, pp. 1727-1737.
  • P. Hippe, R. Döhler: Myelomeningocele. In: Rüdiger Döhler : Lexicon of Orthopedic Surgery . Springer, Berlin / Heidelberg 2003, ISBN 3-540-41317-0 , pp. 126-127.
  • K. Parsch, K.-P. Schulitz: The spina bifida child - clinic and rehabilitation . Thieme, Stuttgart 1972.
  • LL Tosi, BD Buck, SS Nason, DW McKay: Dislocation of the hip in myelomeningocele. The McKay hip stabilization. In: The Journal of Bone & Joint Surgery. [Am] 78-A, 1996, pp. 664-673.

Individual evidence

  1. ↑ R. Döhler, M. Mann: The hip dislocation in spina bifida children and their treatment . Schleswig-Holsteinisches Ärzteblatt 11/1981, pp. 548–551.
  2. ↑ MB Menelaus: The orthopedic management of spina bifida. 2nd Edition. Livingstone / Edinburgh / London 1980.
  3. ↑ WJW Sharrard, J. Burke: iliopsoas transfer. In: International Orthopedics. 1982.