Medico-surgical management of lower extremity fractures in patients with spinal cord injury: assessment and advice based on a 10-year retrospective study carried out in a university hospital
Dr Alban FOUASSON-CHAILLOUXa, Dr Marc DAUTYa, Dr Marc LE FORTb, Dr Charles DUBOISa, Prof François GOUINc, Prof Yves MAUGARSd, Prof Brigitte PERROUIN-VERBEb
a CHU Nantes, Hôpital St Jacques, MPR locomotrice, b CHU Nantes, Hôpital St Jacques, MPR neurologique, c CHU Nantes, Hôtel Dieu, Clinique Chirurgicale et Orthopédique, d CHU Nantes, Hôtel Dieu, Rhumatologie
Objectives: To evaluate the management of lower extremity fractures in patients with spinal cord injury in a referent university center.
Patients and method: Retrospective monocentric study carrried out in patients with spinal cord injury cared for lower extremity fractures at a University Hospital of Nantes.
Results: In 10 years, 57 fracture events responsible for 61 fractures in 41 patients were managed. Average patient age was 50 years old [22-83], 73.3% of patients were AIS A. The median time to onset of the 1st fracture was 14.2years. The most common sites were distal femur (27.9%), distal (21.3%) and proximal tibia (16.4%). Fracture mechanism was wheelchair fall in 50% of cases. Surgery was carried out for 65.6% of the fractures. At least one medico-surgical complication occurred after 25% of surgical treatments and 57.1% of orthopedic treatments. 42% of the fracture events were followed by hospitalization. 12 patients had dual-energy x-ray absorptiometry performed at the lumbar spine and femoral necks. The average bone mineral density was 0.566g/cm2 at the right femoral neck (T-score: -3.3; Z-score: -2.6), 0.574g/cm2 at the left one (T-score: -3.4; Z-score:-2.8) and 1.07g/cm2 at the lumbar spine (T-score: -0.38; Z-score: -0.21). 11 patients were treated with bisphosphonate.
Discussion: Lower extremity fractures occur close to the knee for low traumas. Surgery seems to provide fewer complications. For sub-lesional bone loss screening, a low bone mineral density is predictive of fractures. The best site of measurement is the distal femur because of reliability and reproducibility. The measurement on the lumbar spine is not recommended. Bisphosphonates have never shown efficacy for the reduction of the number of fractures but allow an increase of bone mineral density.
References: Vestergaard, P., et al. Fracture rates and risk factors for fractures in patients with spinal cord injury. Spinal Cord 36, 790-796 (1998). Dauty, M., et al. Supralesional and sublesional bone mineral density in spinal cord-injured patients. Bone 27, 305-309 (2000).
Keywords : Lower extremity fractures, spinal cord injury, osteoporosis, dual-energy x-ray, absorptiometry, bisphosphonate.