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Is there a functional morbidity of fractures in non-ambulatory pediatric patients with cerebral palsy? Does fracture prevention prevent functional deterioration?

RT MOORE MD, S KISHAN MD, R QUIGLEY

Loma Linda University, Loma Linda, CA, USA

Background/Objectives: The effect of fracture on the functional status of non-ambulatory pediatric cerebral palsy (NAPCP) patients has yet to be reported in the literature. The purpose of this study is to determine if there is a deterioration of functional status at one year post-fracture from pre-fracture levels. In addition, we will report on the age at first fracture, anatomic distribution, and mechanism of injury for specifically NAPCP patients. The goal of this paper is to further the understanding of fractures in this sub-population of CP patients.

Design: Retrospective consecutive case series.

Participants and Setting: Our institution’s ICD-9 database (representing ER and outpatient encounters from 2001 to 2007) was used to identify patients aged 4-17 years who were treated for a fracture and who had CP. Exclusion criteria were ability to ambulate, inadequate information to classify functional status, and incorrectly ICD-9 coded patients. We initially identified 41 patients. Twelve were excluded for the above reasons, leaving 29 patients with 49 fractures.

Materials/Methods: After expedited IRB approval, data was obtained by telephone interview and chart review. Data included age at fracture(s), anatomic location, motor type, gross motor function classification score (GMFCS) and functional mobility score (FMS) pre and one year post-fracture. Descriptive statistics were used to analyze our data for both categorical and numeric observations.

Results: At the time of fracture, 86% of NAPCP patients were GMFCS V (88% of fractures), 14% GMFCS IV (12% of fractures). Ninety-six percent of fracture occurred in patients who scored a pre-fracture FMS at 5, 50, and 500 m of N, N, N. Only one patient who sustained simultaneous bilateral proximal femur fractures experienced measurable functional loss, deteriorating from a FMS of C, N, N to N, N, N. No fracture led to a loss of GMFCS. Ninety percent of fractures occurred in spastic quadriplegics. Mean age at fracture was 10.46 (SD 3.44). Six percent of fractures were in the upper extremity (all proximal humerus), 94% lower extremity, 84% metaphyseal, 42% distal femur, 12% femoral diaphysis, 8% proximal femur, 4% proximal tibia, 4% tibial diaphysis and 20% distal tibia.

Conclusions/Significance: The majority of fracture, 88%, occurred in patients who were GMFCS V and could therefore not result in measurable functional loss. Additonally, there was no loss of GMFC level in those who were GMFCS IV, but due to small sample size it is difficult to draw conclusions. One patient had a pre-fracture FMS better than N, N, N and he did have loss of function. As prophylactic treatments are utilized that may carry the risk of long-term complications to our patients, it is important to consider what clinical gains will be made. The overall morbidity of fractures in this population (quality of life, pain, expense, etc.) needs to be better quantified so that an informed risk/benefit analysis can be made. Although other benefits may be expected, motor function will be largely unaffected by fracture prevention.

 
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