Management of lower limb fractures in patients with spinal cord injuries

Malunions following lower extremity fractures in veterans with a spinal cord injury/disorder

BACKGROUND

Nearly 50% of all persons with a spinal cord injury/disorder (SCI/D) will sustain an osteoporotic fracture sometime in their life, with lower extremity fractures being the most common. There are a number of complications that can occur post fracture, including fracture malunion. To date, there have been no dedicated investigations of malunions among persons with SCI/D.

OBJECTIVES

The primary objective of this study was to identify risk factors associated with fracture malunion among fracture-related (type of fracture, fracture location, initial fracture treatment) and SCI/D-related factors. Secondary objectives were to describe treatment of fracture malunions and complications following these malunions.

METHODS

Veterans with SCI/D with an incident lower extremity fracture and subsequent malunion from Fiscal Year (FY) 2005-2015 were selected from the Veteran Health Administration (VHA) databases using International Classification of Diseases, 9th edition (ICD-9) codes for lower extremity fractures and malunion. These fracture malunion cases underwent electronic health record (EHR) review to abstract information on potential risk factors, treatments and complications for malunion. Twenty-nine cases were identified with a fracture malunion with 28 of them successfully matched with Veterans with a lower extremity fracture during FY2005-FY2014 without a malunion (matched 1:4) based on having an outpatient utilization date of care within 30 days of the fracture case. There was trend towards more nonsurgical treatment in the malunion group (n = 27, 96.43%) compared to the control group (n = 101, 90.18%) (P = 0.05), though fracture treatment proved not to be not associated with developing a malunion in univariate logistic regression analyses (OR = 0.30; 95% CI: 0.08-1.09). In multivariate analyses, Veterans with tetraplegia were significantly less likely (approximately 3-fold) to have a fracture malunion (OR = 0.38; 95% CI: 0.14-0.93) compared to those with paraplegia. Fracture malunion was significantly less likely to occur for fractures of the ankle (OR = 0.02; 95% CI: 0-0.13) or the hip (OR = 0.15; 95% CI: 0.03-0.56) compared to femur fractures. Fracture malunions were rarely treated. The most common complications following malunions were pressure injuries (56.3%) followed by osteomyelitis (25.0%).

CONCLUSIONS

Persons with tetraplegia as well as fractures of the ankle and hip (compared to the femur) were less likely to develop a fracture malunion. Attention to prevention of avoidable pressure injuries following a fracture malunion is important.

Rehabilitation Towards Functional Independence in a Patient With Intertrochanteric Fracture and Paraplegia: A Case Report

Traumatic spinal cord injury (SCI) causes significant neurological deficits that adversely affect the quality of life of patients and caregivers. Patients with SCI present with the symptoms of weakness and loss of sensations in the limbs. Motor deficits may occur in the form of paraplegia, hemiplegia, or quadriplegia. Patients remain immobilized for a prolonged period which may lead to complications like muscle wasting, atrophy, joint stiffness, contractures, bed sores, and osteoporosis. Patients are prone to fractures owing to osteoporosis. The fractures may occur even due to trivial trauma. Our case report presents the case of a 45-year-old male patient who is already diagnosed with paraplegia having a history of SCI one-and-a-half years ago. He has recent history of intertrochanteric (IT) fracture that occurs during the transfer from bed to wheelchair. Admitted to the hospital with a complaint of a popping sound along with low back pain. Further investigation and management were started.

Appendicular fracture and polytrauma correlate with outcome of spinal cord injury (SCI): A TRACK-SCI study

Spinal cord injuries (SCIs) frequently occur in combination with other major organ injuries, such as traumatic brain injury (TBI) and injuries to the chest, abdomen, and musculoskeletal system (e.g., extremity, pelvic, and spine fractures). However, the effects of appendicular fractures on SCI recovery are poorly understood. We investigated whether the presence of SCI-concurrent appendicular fractures is predictive of a less robust SCI recovery. Patients enrolled in the Transforming Research And Clinical Knowledge in SCI (TRACK-SCI) prospective cohort study were identified and included in this secondary analysis study. Inclusion criteria resulted in 147 patients consisting of 120 isolated SCIs and 27 with concomitant appendicular fracture. The primary outcome was ASIA Impairment Scale (AIS) neurological grades at hospital discharge. Secondary outcomes included hospital length of stay, ICU length of stay, and AIS grade improvement during hospitalization. Multivariable binomial logistic regression analyses assessed whether SCI-concomitant appendicular fractures associate with SCI function and secondary outcomes. These analyses were adjusted for age, gender, injury severity, and non-fracture polytrauma. Appendicular fractures were associated with more severe AIS grades at hospital discharge, though covariate adjustments diminished statistical significance of this effect. Notably, non-fracture injuries to the chest and abdomen were influential covariates. Secondary analyses suggested that appendicular fractures also increased hospital length of stay. Our study indicated that SCI-associated polytrauma is important for predicting SCI functional outcomes. Further statistical evaluation is required to disentangle the effects of appendicular fractures, non-fracture solid organ injury, and SCI physiology to improve health outcomes amongst SCI patients.