Acute Lower Extremity Fracture Management in Chronic Spinal Cord Injury

L.D. Carbone, MD; J. Ahn, MD, PhD; R.A. Adler, MD; T. Cervinka, MD; C. Craven, MD; W. Geerts, MD; J.R. Hsu, MD; D. Huang, MD; M.A. Karunakar, MD; B.J. Kiratli, PhD; P.C. Krause, MD; L.R. Morse, DO; G.E. Mirick Mueller, MD; A. Nana, MD; E. Rogers, PT; J.C. Rivera, MD; C. Spitler, MD; F.M. Weaver, PhD; W. Obremskey, MD, MPH, MMHC

doi:10.2106/JBJS.OA.21.00152

JBJS Open Access (Dec 2022)

Acute Lower Extremity Fracture Management in Chronic Spinal Cord Injury

L.D. Carbone, MD,
J. Ahn, MD, PhD,
R.A. Adler, MD,
T. Cervinka, MD,
C. Craven, MD,
W. Geerts, MD,
J.R. Hsu, MD,
D. Huang, MD,
M.A. Karunakar, MD,
B.J. Kiratli, PhD,
P.C. Krause, MD,
L.R. Morse, DO,
G.E. Mirick Mueller, MD,
A. Nana, MD,
E. Rogers, PT,
J.C. Rivera, MD,
C. Spitler, MD,
F.M. Weaver, PhD,
W. Obremskey, MD, MPH, MMHC

Affiliations

L.D. Carbone, MD: 1 Charlie Norwood Veterans Affairs Medical Center, Augusta, Georgia
J. Ahn, MD, PhD: 3 Orthopaedic Trauma Service, Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan
R.A. Adler, MD: 4 Central Virginia Veterans Affairs Health Care System, Richmond, Virginia
T. Cervinka, MD: 6 Department of Rehabilitation, Hospital Nova, Jyväskylä, Finland
C. Craven, MD: 7 KITE Research Institute, University Health Network, Toronto, Ontario, Canada
W. Geerts, MD: 9 Thromboembolism Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
J.R. Hsu, MD: 10 Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
D. Huang, MD: 11 Spinal Cord Injury Care Line, Michael E. DeBakey VA Medical Center, Houston, Texas
M.A. Karunakar, MD: 10 Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
B.J. Kiratli, PhD: 13 Spinal Cord Injury Center, VA Palo Alto Health Care System, Palo Alto, California
P.C. Krause, MD: 14 Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana
L.R. Morse, DO: 15 Department of Rehabilitation Medicine, University of Minnesota School of Medicine, Minneapolis, Minnesota
G.E. Mirick Mueller, MD: 16 Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Minnesota
A. Nana, MD: 18 Department of Orthopaedic Surgery, JPS Health Network, Fort Worth, Texas
E. Rogers, PT: 19 Spinal Cord Injury Service, VA Puget Sound Health Care System, Seattle, Washington
J.C. Rivera, MD: 14 Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana
C. Spitler, MD: 20 Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
F.M. Weaver, PhD: 21 Center of Innovation for Complex Chronic Healthcare (CINCCH), Health Services Research & Development, Department of Veterans Affairs, Hines VA Hospital, Hines, Illinois
W. Obremskey, MD, MPH, MMHC: 23 Center for Musculoskeletal Research, Division of Orthopaedic Trauma, Vanderbilt Orthopaedic Institute, Vanderbilt University Medical Center, Nashville, Tennessee

DOI: https://doi.org/10.2106/JBJS.OA.21.00152
Journal volume & issue: Vol. 7, no. 4

Abstract

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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.

Published in JBJS Open Access

ISSN: 2472-7245 (Online)
Publisher: Wolters Kluwer
Country of publisher: United States
LCC subjects: Medicine: Surgery: Orthopedic surgery
Website: http://journals.lww.com/jbjsoa

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