Fracture of the Tibia in Spina Bifida Vera

Abstract

Neuropathic lesions in the lower extremities developing in patients with spina bifida vera are well recognized. Perforating ulcers of the feet and neuropathic joints have been described. The changes observed following fractures of the tibia in two of our patients with spina bifida vera, club foot deformities, and sensory disturbances of the lower extremities are of sufficient radiographic interest to warrant reporting. Case 1. J. W., a girl five years old, was readmitted to the hospital on July 12, 1937, with a provisional diagnosis of sarcoma of the left leg. This child had previously been treated in the Department of Orthopedics for bilateral club feet associated with spina bifida vera. She was last seen by them in January, 1937, and was sent home wearing short leg braces. Present Illness.—On June 20, 1937, the child began to complain of aching pain along the medial aspect of the upper third of the right leg. Five or six days later the mother noticed swelling on the lateral surface just below the knee. When off her feet the swelling would subside and pain was relieved. A week before admission it was noted that swelling was constant. There was no history of a specific trauma although the child was awkward and fell frequently. Physical Examination.—The child was a well developed, and well nourished girl of five. Examination of the back showed a large spina bifida vera at the level of the twelfth dorsal, first and second lumbar vertebrse. The accompanying soft tissue tumor measured 14 × 12 cm. in size. The right leg showed a large mass 9.5 × 9.5 cm., located along the lateral anterior and medial aspects of the upper third. This was attached to the deep structures but not to the skin. There was no tenderness to palpation. The overlying skin was tense, hyperemic, and definitely warmer than the corresponding area on the left leg. However, the mother stated that the right leg had always been warmer than the left. Neurologic Findings.—There was complete anesthesia of the lateral, and reduced sensibility of the medial aspect of both legs. The knee jerks, tendo-Achilles, and plantar reflexes were absent. It was felt by the examining neurologist that the sensory reduction and absence in the lower extremities would allow a fracture in the upper right tibia to cause very little discomfort. Radiographic Examination.—Anteroposterior and lateral films of the right leg showed definite: enlargement of the upper leg below the knee (Fig. 1). There was a transverse, somewhat irregular fracture line 3 cm. below the upper end of the tibia. The fragments were in full apposition. Posterior and medial to the fracture there was a mass of new bone 2.5 cm. in its superior-inferior, 1.5 cm. in its anteroposterior, and 1 cm. in its lateral diameter. This newly deposited bone showed no evidence of striation or trabeculation.