Acute Lower Extremity Fracture Management in Chronic Spinal Cord Injury

Abstract

Background: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.

The Pathophysiology, Identification and Management of Fracture Risk, Sublesional Osteoporosis and Fracture among Adults with Spinal Cord Injury

“…The goal for the treatment of osteoporotic fractures, whether done operatively or non-operatively, is to return the individual to their pre-fracture level of mobility and independence [ 162 , 163 ]. Treatment choices should be guided by an ascertainment of the risks and benefits of operative versus non-operative approaches, the person’s premorbid level of function and consideration for the impact of fracture management strategies on the ability to use both current and future mobility technologies [ 12 ]. Regarding the latter, the effects of the fracture treatment modality on the range of motion are important to consider as current robotic exoskeleton devices require a specific range of motion for hip and knee extension and neutral ankle-joint positions [ 159 , 164 , 165 , 166 , 167 , 168 , 169 , 170 , 171 , 172 ].…”

“…Regarding the latter, the effects of the fracture treatment modality on the range of motion are important to consider as current robotic exoskeleton devices require a specific range of motion for hip and knee extension and neutral ankle-joint positions [ 159 , 164 , 165 , 166 , 167 , 168 , 169 , 170 , 171 , 172 ]. Education on the risks and benefits of operative compared with non-operative approaches should be provided, and shared decision-making should form the basis for the fracture treatment [ 12 ]. However, the extent to which this is happening in clinical practice is not clear.…”

“…Such non-operative strategies have traditionally been considered the treatment of choice for fractures, as historically surgical treatment of fractures was associated with high complication rates [ 180 , 184 ]. A CPG for the management of acute fractures concluded that if non-operative therapies are chosen, these should be well padded with attention to neutral rotation alignment and should allow for frequent skin inspection [ 12 ]. No specific recommendations for particular immobilization devices were given [ 12 ].…”

“…Clinical considerations when selecting drug or rehab therapy for the treatment of osteoporosis or optimal fracture management and criteria for stopping ineffective therapy are discussed. The authors acknowledge that the majority of the data that comprise the scientific underpinning of the consensus documents summarized herein [ 10 , 11 , 12 ] are based on data stemming from patients with traumatic SCI and may not be universally applicable to patients with SCI or disease. Readers are encouraged to read this review and the related consensus documents [ 10 , 11 , 12 ] in entirety to have a full appreciation of the concepts and nuances of practice.…”

“…The authors acknowledge that the majority of the data that comprise the scientific underpinning of the consensus documents summarized herein [ 10 , 11 , 12 ] are based on data stemming from patients with traumatic SCI and may not be universally applicable to patients with SCI or disease. Readers are encouraged to read this review and the related consensus documents [ 10 , 11 , 12 ] in entirety to have a full appreciation of the concepts and nuances of practice. Health services to prevent fracture among adults with chronic SCI are optimally provided by an interprofessional team with effective communication skills and a strong emphasis on patient and family caregiver education and shared decision making.…”