Carroll N C
Department of Orthopaedics, Northwestern University School of Medicine, Chicago, Illinois.
Orthop Clin North Am. 1987 Oct;18(4):709-24.
The goal in managing the lower extremity in a child with spina bifida is to achieve a pattern of development as near normal as possible. Lower limb deformities are produced by muscle imbalance, weight-bearing, and the postural effects of gravity. At any point in time, the management of the lower extremities will depend on the child's general development. Lower limb paralysis, hydrocephalus, bladder infections, hydromyelia, and Arnold Chiari malformation, all contribute to developmental delay. A child's potential for mobility varies with the severity of the motor and sensory deficit. Surgery is done to correct deformity, provide joint stability, and improve joint mobility. The results of surgery will be compromised if the child is not neurologically stable, or if appropriate therapy and orthotic care are not available. Muscle imbalance produces the problem of deformity and instability of the hip. Deformity must be corrected if the child is to assume an upright posture. Instability is of concern only in those children with a strong quadriceps muscle. Hip surgery for instability should be limited to one procedure, which must achieve a stable concentric reduction and balance the muscle forces about the hip. The common deformities seen at the knee are recurvatum, knee flexion contractures, and genu valgum. Most knee deformities can be corrected by soft tissue procedures. Well-designed orthoses rocker sole shoes, and appropriate gait training help prevent knee deformities. The goal in managing foot deformities is to achieve a plantigrade foot with stable skin. Whenever there is a problem with sensation, concentrated pressure in one area of a deformed foot will lead to skin breakdown. Surgical procedures must completely correct deformity and restore muscle imbalance. After surgery, meticulous orthotic care is required to prevent skin breakdown and avoid loss of correction. The orthopedist has a significant role in helping a child with spina bifida to achieve a pattern of development as near normal as possible. He or she must work in concert with a team of professionals and realize that orthopedic surgery is but an incident in the habilitative program. This rather chatty narrative is based on spina bifida care experience, in Sheffield, Toronto, and Chicago.
管理患有脊柱裂儿童的下肢的目标是实现尽可能接近正常的发育模式。下肢畸形是由肌肉失衡、负重以及重力的姿势影响所导致的。在任何时间点，下肢的管理都将取决于儿童的总体发育情况。下肢瘫痪、脑积水、膀胱感染、脊髓空洞症和阿诺德·奇亚里畸形，都会导致发育迟缓。儿童的活动能力潜力因运动和感觉缺陷的严重程度而异。进行手术是为了矫正畸形、提供关节稳定性并改善关节活动度。如果儿童神经不稳定，或者没有适当的治疗和矫形护理，手术效果将会受到影响。肌肉失衡会导致髋部畸形和不稳定问题。如果儿童要保持直立姿势，就必须矫正畸形。只有在股四头肌强壮的儿童中，不稳定才是一个问题。针对不稳定的髋部手术应限于一次手术，该手术必须实现稳定的同心复位并平衡髋部周围的肌肉力量。在膝盖处常见的畸形有膝反屈、膝关节屈曲挛缩和膝外翻。大多数膝盖畸形可以通过软组织手术矫正。精心设计的矫形器、摇摆底鞋和适当的步态训练有助于预防膝盖畸形。管理足部畸形的目标是实现具有稳定皮肤的足底着地足。只要存在感觉问题，畸形足部某一区域的集中压力就会导致皮肤破损。手术程序必须完全矫正畸形并恢复肌肉失衡。手术后，需要精心的矫形护理以防止皮肤破损并避免矫正丢失。骨科医生在帮助患有脊柱裂的儿童实现尽可能接近正常的发育模式方面发挥着重要作用。他或她必须与一组专业人员协同工作，并认识到骨科手术只是康复计划中的一个环节。这段相当随意的叙述基于在谢菲尔德、多伦多和芝加哥的脊柱裂护理经验。
