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Objectives: Long bone fractures pose serious health concerns to individuals with spinal cord injury. There are no established consensus guidelines on treatment and little understanding of mechanisms of bone failure. Our objectives were to identify risk factors and causes of long bone fractures in these individuals and to evaluate the morphology of these fractures in relation to their causes. We also evaluated the sequelae of these fractures in terms of complications and care needs.
Clinical Relevance: This study provides new information about patterns of fracture in patients with SCI and how fractures affect individuals with SCI and their daily functioning. These data will assist us in determining preventable causes of fractures and setting up guidelines in order to implement prevention. Results from this study should also be useful in projecting costs and health care needs for fracture care in the spinal cord injury population.
Methods: Demographic and medical data were collected on 700 patients with spinal cord injury ever seen at the VA Palo Alto Health Care System, and fracture history was determined. In patients who had sustained long bone fractures since their injury, detailed data collection regarding fracture cause, morphology, and patient-related outcomes was conducted by medical chart review, review of radiologic records, and interviews.
Results: A total of 252 fractures in 181 patients were identified; these occurred 16.1 years (SD=10.8) after spinal cord injury (range: 0.5 - 53.9 years). The fractures were distributed as follows: 117 (46%) femur, 112 (44%) tibia/fibula, 16 (6%) radius/ulna, and 7 (3%) humerus. Comprehensive study was completed on 170 fractures, with focus was on fractures of the lower extremity. In the femur, 25% occurred proximally, 33% in the midshaft, and 43% distally. In the tibia, the distribution of fractures was 45% proximally, 28% in the midshaft, and 26% in the distal segment. Most of the proximal and distal femur and tibia fractures were extra-articular. The majority of femur and tibia shaft fractures (64%) were simple (ie, not wedge or complex). The most common cause of fracture for both femur and tibia in all segments was falls (48%, not including falls during a transfer). Other common causes included 20% transfer activities and 10% range of motion and activities of daily living. The majority of fractures required hospitalization, and 67% of the patients who sustained fractures needed extra assistance with their daily activities for some time afterward. The highest percentage of patients who required extra assistance were those with distal femur fracture (78%) followed by those with tibia midshaft fractures (75%). Overall, the occurrence of complications was low.
Conclusions: Over 25% of all patients ever seen at our facility have experienced at least one long bone fracture with an average of 2.7 fractures per patient. The majority of these occurred around the knee joint and most resulted from falls and transfer activities. Long bone fractures had a significant impact on independence in a high proportion of patients which has financial implications when the need for extra assistance involves care provided by an attendant.
Acknowledgments: VA Rehabilitation R & D Merit Review Grant #A2014-RA