Acute Lower Extremity Fracture Management in Chronic Spinal Cord Injury

Publication Date: December 7, 2022
Last Updated: January 6, 2023

Summary of Recommendations

Section I: Acute Fracture Treatment
  • 1.1 Recommendation We recommend that patients with an SCI who sustain a lower extremity fracture be provided with education regarding the risks and benefits of operative and nonoperative management. We recommend that shared decision-making between patient and provider be conducted when making a decision regarding definitive fracture management.
    • Grade: 1D
  • 1.2 Recommendation We recommend that consultation with an orthopaedic surgeon and engagement of appropriate multidisciplinary teams, as clinically indicated, should be done as soon as possible when a lower extremity fracture is identified.
    • Grade: 1D
  • 1.3 Recommendation We recommend operative management for open lower extremity fractures. These fractures should be treated with irrigation and debridement, with appropriate antibiotic coverage and wound closure as soon as possible to reduce complications related to infection, and surgical stabilization should be considered. We recommend operative management for any lower extremity fracture that the orthopaedic surgeon determines will not reliably heal in a position that will restore the patient to their pre-fracture functional status.
    • Grade: 1C
    • Clinical Considerations: Operative management of these fractures with appropriate antibiotic coverage should be performed as soon as feasible when the patient is medically stable. Treatments should take into account the severity of the open fracture and should follow EBQVS Committee recommendations.
  • 1.4 Recommendation We recommend that factors to consider in decision-making relative to fracture treatment are the risks and benefits of operative versus nonoperative approaches for the individual patient, the premorbid level of function, patient preferences, and the impact of fracture management strategies on vocation, avocation, independence, and the use of current and future mobility technologies.
    • Grade: 1C
  • 1.5 Recommendation If operative management is chosen, we recommend the following, in conjunction with physical therapy.
    • Hip
      • Femoral neck (intracapsular)
        • Nondisplaced: Internal fixation.
        • Displaced: Arthroplasty or resection. Resection can be considered but raises risk of proximal femoral migration and subsequent pressure injury and sitting imbalance.
      • Intertrochanteric: Internal fixation with intramedullary nail (IMN) fixation.
      • Subtrochanteric: Internal fixation with a long IMN, with fixation into the femoral head.
    • Femur
      • Proximal and mid-shaft: Internal fixation spanning the entire femur, with fixation into the femoral head. Consideration for supplemental fixation as needed.
      • Distal: Internal fixation (plate or IMN, or plate and IMN in combination).
    • Tibia/Fibula
      • Proximal/mid-shaft: Internal fixation or external fixation (consideration for a circular fixator).
      • Distal: Internal fixation or external fixation (consideration for a circular fixator).
    • Ankle
      • Internal fixation or external fixation (consideration for a circular fixator).
    • Foot
      • Internal fixation, external fixation (consideration for a circular fixator), or percutaneous fixation.
    • Grade: 1C
    • Clinical Considerations: The advent of Exoskeleton Assisted Walking (EAW) has led to an appreciation that persons with an SCI have a high predisposition for foot and ankle fractures. The bone mineral density (BMD) of the calcaneus/foot likely will be markedly reduced, and the patient should avoid early return to weight-bearing activities after healing of the fracture because of the high risk of refracture with upright activities.
  • 1.6 Recommendation If nonoperative management is chosen, we recommend the following.
    • Utilization of well-padded immobilization devices (or well-padded support of the fracture site when immobilization is not feasible), with attention to pressure relief over osseous prominences.
    • Immobilization devices should allow for easy and frequent skin inspection and should maintain neutral rotation and alignment.
    • Grade: 1D
  • 1.7 Recommendation If nonoperative management is chosen, we recommend the following, in conjunction with physical therapy.
    • Hip
      • A well-padded positioning support with attention to neutral rotation and alignment. Range of motion may be as tolerated if the hip fracture is relatively nondisplaced and stable, with monitoring for worsening fracture characteristics (e.g., displacement) and rotation/alignment. Range-of-motion exercises are not recommended for unstable intertrochanteric or subtrochanteric fractures.
    • Femur
      • Proximal/mid-shaft: A well-padded immobilization device.
      • Distal: A well-padded immobilization device with transition to a hinged brace when there is clinical/radiographic evidence of stability.
    • Tibia/Fibula
      • Proximal/mid-shaft: A long-leg well-padded immobilization device with transition to a shorter padded immobilization device when there is clinical/radiographic evidence of stability.
      • Distal: A well-padded immobilization device.
    • Ankle
      • A well-padded positioning support device.
    • Foot
      • A well-padded positioning support device.
    • Grade: 1D

Section II: Role of Physical Therapy: Functional, Positional, and Mobility Considerations
  • 2.1 Recommendation We recommend that therapists (physical therapists [PTs], kinesiotherapists [KTs], and occupational therapists [OTs]) should be involved in fracture rehabilitation as soon as possible to assess equipment needs, skills training, and caregiver assistance due to changes in mobility.
    • Grade: 1D
    • Clinical Considerations: When fractures are managed nonoperatively, the involvement of/consultation with PTs prior to the selection of braces should be considered. During the acute management phase, the focus should be on access to the environment and return to the prior level of their living situation. After acute management, return to the full prior level of participation in activities, including leisure and recreational activities, should be a priority. If the patient is unable to return to their prior living situation after the fracture, social workers should be involved to assist.
  • 2.2 Recommendation We recommend that orthopaedic surgeons engage in early and ongoing communication with therapists regarding range of motion, weight-bearing, and transfer restrictions and that these instructions should be updated as fracture-healing progresses.
    • Grade: 1D
  • 2.3 Recommendation We recommend that someone who is knowledgeable in wheelchair seating (e.g., physical medicine and rehabilitation/physiatrist, physical therapist, or a wheelchair specialist if available) should be involved in post-fracture care for wheelchair users to assess needs related to support of the fractured limb, alignment abnormalities, limb-length discrepancies, and/or seating posture during and following fracture management.
    • Grade: 1D

Section III: Post-Fracture Complications
  • 3.1 Recommendation We suggest surgical intervention for the treatment of (1) a nonunion or malunion associated with residual deformity that impairs functional ability or (2) a fracture that has converted to an open fracture following the failure of nonoperative treatment.
    • Surgical treatment should be considered for a National Pressure Ulcer Advisory Panel (NPUAP) Stage-3 or 4 pressure injury that has failed to heal with conservative therapy.
    • Grade: 2D
    • Clinical Considerations: Orthopaedic options following the failure of nonoperative treatment of a lower extremity long-bone fracture depend on the clinical situation and may include excision or resection of bone or soft tissue, malunion or nonunion correction, fracture fixation, wound debridement and closure, soft-tissue release, or amputation.
  • 3.2 Recommendation We suggest that individuals with an SCI and an acute lower extremity fracture should be monitored for the development of acute compartment syndrome.
    • Grade: 2D
    • Clinical Considerations: Monitoring of creatine phosphokinase (CPK) levels and renal function may be necessary to assist in determining the rare need for fasciotomy or debridement.
  • 3.3 Recommendation We suggest that nonsteroidal anti-inflammatory drugs (NSAIDs) may be considered to prevent progression of heterotopic ossification (HO) post-fracture.
    • Grade: 2D
    • Clinical Considerations: We suggest that excision of HO should only be considered in persons in whom the HO location and configuration place the patient at risk for NPUAP Stage-3 or 4 pressure injury or interfere with necessary range of motion for function, after confirmation that no vascular structures are encased within the HO. Second and third-generation bisphosphonates should not be used to treat HO.
  • 3.4 Recommendation We suggest that clinicians consider using parathyroid analogues such as teriparatide in addition to operative or nonoperative treatment for fractures that are at risk for nonunion (e.g., distal femoral fractures, unstable tibial fractures) during the acute fracture-healing period.
    • Grade: 2D
  • 3.5 Recommendation We suggest that if nonunion affects functional activity or creates pressure concerns, providers should consider referral to a metabolic bone specialist for use of teriparatide and/or surgical intervention to attain union. If a malunion affects functional activity or creates pressure concerns, providers should consider surgical interventions.
    • Grade: 2D
  • 3.6a Recommendation We recommend that clinicians routinely assess the risk of venous thromboembolism (VTE) following an acute lower extremity fracture.
    • Grade: 1C
  • 3.6b Recommendation We recommend that, following an acute lower extremity fracture, clinicians routinely provide anticoagulant thromboprophylaxis with a low-molecular-weight heparin (LMWH) or a direct oral anticoagulant (DOAC) (if there are no contraindications) or obtain the advice of a health professional with expertise in the area of thromboprophylaxis, such as an SCI rehabilitation physician, hematologist, thrombosis specialist, or internist.
    • Grade: 1D
  • 3.6c Recommendation We recommend that thromboprophylaxis start as soon after the fracture as is feasible.
    • Grade: 1C
  • 3.6d Recommendation We suggest that, for persons who are admitted to the hospital, thromboprophylaxis should continue at least until discharge from acute care and rehabilitation, with consideration of a total duration of at least 2 to 4 weeks.
    • Grade: 2D
  • 3.6e Recommendation We suggest that, for persons with an SCI who are not admitted to the hospital, thromboprophylaxis should continue for a total duration of at least 2 to 4 weeks.
    • Grade: 2D
  • 3.6f. Recommendation We recommend that clinicians proactively consider the risk of increased leg edema and skin injury and utilize multilayered compression wraps to help mitigate these adverse events in those who are at risk.
    • Grade: 1D
  • 3.7a. Recommendation We recommend that clinicians use the Orthopaedic Trauma Association (OTA) post-fracture pain management guidelines and the CanPain SCI guidelines29 to inform decision-making regarding therapy selection for post-fracture pain and neuropathic pain exacerbation, respectively.
    • Grade: 1A
  • 3.7b. Recommendation We suggest that clinicians monitor persons who have an SCI and a recent lower extremity fracture for signs and symptoms of inadequate pain management triggering autonomic dysreflexia (AD) in the first 48 to 72 hours post-fracture28.
    • Grade: 2D
  • 3.7c. Recommendation We suggest that surgeons consult a pain specialist or the treating physiatrist if the individual with an SCI, prior to the fracture, was on >100 morphine milligram equivalents (MME)/day of extended-release opioids or >3 concurrent medications for the management of neuropathic pain.
    • Grade: 2D
  • 3.7d. Recommendation We recommend a referral for psychological support following a lower extremity fracture in patients with an SCI and a propensity for depression, anxiety, or posttraumatic stress or poor coping strategies (catastrophic thinking and low self-efficacy)30.
    • Grade: 1C
  • 3.7e. Recommendation We recommend that, when selecting post-fracture pain management therapy, clinicians consider the individual’s risk of pain management misuse and monitor for substance use behaviors and psychological indicators during therapy.
    • Grade: 1C
  • 3.7f. Recommendation We recommend that clinicians pay as much attention to the initiation of analgesic medications as to the tapering and discontinuation of these medications during or after fracture-healing.
    • Grade: 1C

Overview

Title

Acute Lower Extremity Fracture Management in Chronic Spinal Cord Injury

Authoring Organization