Acute Lower Extremity Fracture Management in Chronic Spinal Cord Injury: 2022 Delphi Consensus Recommendations

Our objective was to develop a clinical practice guideline (CPG) for the treatment of acute lower extremity fractures in persons with a chronic spinal cord injury (SCI).

METHODS

Information from a previous systematic review that addressed lower extremity fracture care in persons with an SCI as well as information from interviews of physical and occupational therapists, searches of the literature, and expert opinion were used to develop this CPG. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system was used to determine the quality of evidence and the strength of the recommendations. An overall GRADE quality rating was applied to the evidence.

CONCLUSIONS

Individuals with a chronic SCI who sustain an acute lower extremity fracture should be provided with education regarding the risks and benefits of operative and nonoperative management, and shared decision-making for acute fracture management should be used. Nonoperative management historically has been the default preference; however, with the advent of greater patient independence, improved surgical techniques, and advanced therapeutics and rehabilitation, increased use of surgical management should be considered. Physical therapists, kinesiotherapists, and/or occupational therapists should assess equipment needs, skills training, and caregiver assistance due to changes in mobility resulting from a lower extremity fracture. Therapists should be involved in fracture management as soon as possible following fracture identification. Pressure injuries, compartment syndrome, heterotopic ossification, nonunion, malunion, thromboembolism, pain, and autonomic dysreflexia are fracture-related complications that clinicians caring for patients who have an SCI and a lower extremity fracture may encounter. Strategies for their treatment are discussed. The underlying goal is to return the patient as closely as possible to their pre-fracture functional level with operative or nonoperative management.

Insights into treatment and outcome of fracture-related infection: a systematic literature review

INTRODUCTION

Standardized guidelines for treatment of fracture-related infection (FRI) are lacking. Worldwide many treatment protocols are used with variable success rates. Awareness on the need of standardized, evidence-based guidelines has increased in recent years. This systematic literature review gives an overview of available diagnostic criteria, classifications, treatment protocols, and related outcome measurements for surgically treated FRI patients.

METHODS

A comprehensive search was performed in all scientific literature since 1990. Studies in English that described surgical patient series for treatment of FRI were included. Data were collected on diagnostic criteria for FRI, classifications used, surgical treatments, follow-up protocols, and overall outcome. A systematic review was performed according to the PRISMA statement. Proportions and weighted means were calculated.

RESULTS

The search yielded 2051 studies. Ninety-three studies were suitable for inclusion, describing 3701 patients (3711 fractures) with complex FRI. The population consisted predominantly of male patients (77%), with the tibia being the most commonly affected bone (64%), and a mean of three previous operations per patient. Forty-three (46%) studies described FRI at one specific location. Only one study (1%) used a standardized definition for infection. A total of nine different classifications were used to guide treatment protocols, of which Cierny and Mader was used most often (36%). Eighteen (19%) studies used a one-stage, 50 (54%) a two-stage, and seven (8%) a three-stage surgical treatment protocol. Ten studies (11%) used mixed protocols. Antibiotic protocols varied widely between studies. A multidisciplinary approach was mentioned in only 12 (13%) studies.

CONCLUSIONS

This extensive literature review shows a lack of standardized guidelines with respect to diagnosis and treatment of FRI, which mimics the situation for prosthetic joint infection identified many years ago. Internationally accepted guidelines are urgently required to improve the quality of care for patients suffering from this significant complication.

A comparison of transferred versus direct admission orthopedic trauma patients

Trauma patients with orthopedic injuries transferred to Harborview Medical Center (HMC) were compared with all trauma patients directly admitted to HMC and with a set of matched controls regarding injury Severity Score (ISS) and age, if > or = 50 years old. Groups were compared on ISS, Revised Trauma Score (RTS), ICU stay, length of stay (LOS), total charges, reimbursement, payors, and outcome. Comparison of all transferred patients and directly admitted patients showed significant differences in ISS, LOS, ICU stay, and total charges. Despite a higher ISS, transferred patients had no differences in RTS or survival outcome. Comparison of matched transferred patients and directly admitted patients on ISS and age if > or = 50 years old showed a statistically significant increase in LOS, reimbursement, and charges. The survival rate of all transferred and directly admitted trauma patients was approximately 95% for both groups despite a slightly higher degree of injury in transferred patients. The reimbursement rate for both groups was low, 65% for transferred patients and 59% for directly admitted patients. The percentage of transfer patients on Medicaid was 34% and for direct admissions was 37% (p = 0.552). This is a large percentage of indigent care, since only 8.1% of Washington State residents are Medicaid dependent.

Fracture-dislocation of the shoulder in a child: case report

This is a case of an 11-year old girl with a delayed diagnosis of a shoulder fracture-dislocation. Shoulder dislocations are rare, and proximal humerus fractures are uncommon. A fracture-dislocation in a child is, to our knowledge, as yet unrepresented in the English-language literature. The child's injury resolved without recurrence.