A multi-center team of senior researchers and surgeons have published updated guidelines for the treatment of acute lower extremity fractures in people with a chronic spinal cord injury. Among its other findings and conclusions, the authors concluded that surgical management of the fractures should be considered more often than it has been in the past.
Updated Spine Fracture Practice Guidelines Released
3 min read Premium comments
Secondary#chronicspinalinjuries#lowerextremityfractures
The guidelines, “Acute Lower Extremity Fracture Management in Chronic Spinal Cord Injury,” were published online on December 12, 2022, in The Journal of Bone and Joint Surgery.
The consensus opinion of the authors came after reviewing data from a previous systematic review as well as information from interviews of physical and occupational therapists, searches of literature and expert opinion.
In summary, the updated consensus guidelines are that:
- Individuals with a chronic spinal cord injury who experience an acute lower extremity fracture should be informed of the risks and benefits of operative and nonoperative management
- Doctors and patients should use shared decision-making for acute fracture management
- Physical therapists, kinesiotherapists, and/or occupational therapists should be involved in assessing the patient’s equipment needs, skills training, and caregiver assistance due to changes in mobility from the fracture
- Therapists should be involved in fracture management as soon as possible after the fracture is identified
- Clinicians treating these patients may encounter complications such as pressure injuries, compartment syndrome, heterotopic ossification, nonunion, malunion, thromboembolism, pain, and autonomic dysreflexia
“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,” the team wrote.
“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 orthopedic surgeon determines will not reliably heal in a position that will restore the patient to their pre-fracture functional status.”
The team was truly an extensive and senior group. They included:
- D. Carbone, M.D., of Charlie Norwood Veterans Affairs Medical Center and Augusta University in Augusta, Georgia
- Ahn, M.D., Ph.D. of University of Michigan, Ann Arbor, Michigan
- A. Adler, M.D., of Central Virginia Veterans Affairs Health Care System and Virginia Commonwealth University in Richmond, Virginia
- Cervinka, M.D., Hospital Nova, Jyväskylä, Finland
- Craven, M.D., of KITE Research Institute, University Health Network, Toronto, Ontario, Canada and University of Toronto in Toronto, Ontario, Canada
- Geerts, M.D., of the University of Toronto, Toronto, Ontario, Canada
- R. Hsu, M.D., of Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
- Huang, M.D., of Michael E. DeBakey VA Medical Center and Baylor College of Medicine in Houston, Texas
- A. Karunakar, M.D., of Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
- J. Kiratli, Ph.D., of VA Palo Alto Health Care System in Palo Alto, California
- C. Krause, M.D., of Louisiana State University Health Sciences Center in New Orleans, Louisiana
- R. Morse, DO, of University of Minnesota School of Medicine, Minneapolis, Minnesota
- E. Mirick Mueller, M.D., of University of Minnesota and Hennepin County Medical Center in Minneapolis, Minnesota
- Nana, M.D. of JPS Health Network, Fort Worth, Texas
- Rogers, PT, of VA Puget Sound Health Care System, Seattle, Washington
- C. Rivera, M.D., of Louisiana State University Health Sciences Center, New Orleans, Louisiana
- Spitler, M.D. of University of Alabama at Birmingham in Birmingham, Alabama
- M. Weaver, Ph.D. Center of Innovation for Complex Chronic Healthcare (CINCCH), Health Services Research & Development, Department of Veterans Affairs, Hines VA Hospital, Hines, Illinois and Parkinson School of Health Sciences and Public Health, Loyola University, Maywood, Illinois
- W. Obremskey, M.D., M.P.H., MMHC, of Vanderbilt Orthopaedic Institute, Vanderbilt University Medical Center in Nashville, Tennessee.
React:
Discussion
This is a fascinating development. In my practice we've seen similar outcomes with the revised protocol. The key differentiator seems to be patient selection criteria. Has anyone else noticed the correlation with BMI thresholds?
Great point. I'd push back slightly on the conclusion, the sample size in the cited study is too small to draw population-level inferences. That said, the directional signal is compelling and worth a larger RCT.
We implemented a similar approach last year. Early results are promising but we're still gathering 12-month follow-up data. Happy to share our protocol if anyone is interested.
Join the conversation
Orthopedic professionals are discussing this. Sign in and upgrade to read every comment and add your voice.