Soft-plastic brace for lower limb fractures in patients with spinal cord injury

Atraumatic Fractures in Multi-Morbid Older Adults: A Series of Five Cases and Review of Literature

Atraumatic fractures (ATFs) are a fragility fracture subtype with occasional medicolegal issues. ATFs are defined as fractures because of a "low-energy mechanism that is usually considered incapable of producing a fracture." They are an underreported disorder, with epidemiological variations. ATF phenomena were previously reported not only in older adults, but also in children, young adults, older adults, and animals. This study is a short retrospective case series exploring atraumatic fractures in a tertiary care university hospital. Over a period of two years, a total of seven ATF cases were identified. However, only five fulfilled the inclusion criteria. Local causes of pathologic fractures (e.g., metastasis) and elder abuse or neglect were excluded. Comparison of the cases' clinical profile, fracture profile, and management was done. All five cases were frail females with significant osteotoxic burdens from medications and multi-morbidities. ATF presentations included typical (as pain) and atypical (as painless, loud crack, and sudden giveaway) symptomatology. One ATF had a coincident unexplained aseptic fever. Three cases had more than one fracture (fracture cascade), confirmed and followed up by x-rays. All the cases were managed conservatively except for one case that underwent hip hemiarthroplasty. Plans of care included managing the osteotoxic multi-morbidities burden, focusing on the whole body, not only on the fracture or bone. The study provided insights about challenges in presentations of ATF (as the bone fracture acute phase reaction: osteogenic aseptic fever). Risk factors are classically assumed to be osteoporosis, but it is usually systemic and multifactorial. A high risk of fracture warning sign could help decrease ATF occurrence or fracture cascades. Four ATF categories were detected to help healthcare systems identify high-risk patients and raise awareness among medical staff, families, and caregivers. Future studies of the at-risk groups are needed to understand ATF knowledge gaps, challenges, and the best treatments.

Suitability of skin traction combined with braces for treating femoral shaft fractures in 3-5 years old children

BACKGROUND

In children aged 3-5 years, femoral fractures are common and are frequently treated using flexible intramedullary nails (FIN) or spica casting. Recently, more surgeons have been relying on FIN surgery because of the high rate of complications associated with spica casts, such as skin irritation and re-adjustment surgery. We aimed to evaluate the effect of skin traction combined with braces in 3-5 years old children at our hospital.

METHODS

We retrospectively analyzed 125 children aged 3-5 years with femoral shaft fractures treated at our hospital between January 2010 and December 2020. We assigned 68 patients who underwent FIN surgery to Group A and 57 patients treated with skin traction and braces to Group B. Comparative analysis included the children's age, sex, side of the affected limb, cause of fracture, function of the knee joint, healing time of the fracture, duration of hospitalization, cost of hospitalization, and complications. The complications evaluated included joint dysfunction, pain, infection, pressure ulcers, angular deformities, limb length differences, re-fractures, nonunion fractures, and delayed union.

RESULTS

There were significant differences in and hospital costs (p = 0.001). Conversely, no statistically significant differences were observed in sex (p = 0.858), injury type (p = 0.804), age (p = 0.231), hospitalization time (p = 0.071), bone healing time (p = 0.212), and complications. Pressure ulcers, nonunion fractures, and delayed union did not occur in both groups.

CONCLUSION

Both methods had similar therapeutic effects and postoperative complications in children aged 3-5 years with femoral shaft fractures. Therefore, skin traction combined with braces is recommended for this population and for patients hospitalized in institutions where several beds are available, with a consequent possibility of prolonged hospitalization.

LEVEL OF EVIDENCE

IV.

Treatment of Lower Extremity Fractures in Chronic Spinal Cord Injury: A Systematic Review of the Literature

OBJECTIVE

To review the literature regarding outcomes of surgical and nonsurgical management of lower extremity (LE) fractures in chronic spinal cord injury (SCI). TYPE: Systematic review.

LITERATURE SURVEY

Medline (PubMed), Embase, Cochrane Database of Systemic Reviews, Cochrane Central, Cumulative Index to Nursing and Allied Health Literature, ClinicalTrials.gov, International Clinical Trials Registry Platform, and International Standard Randomized Controlled Trials were searched from January 1, 1966, to March 1, 2019.

METHODOLOGY

Search was restricted to English language and adults (age ≥ 18 yr). Titles and abstracts were reviewed for relevance to study topics for inclusion. Case reports, reviews, non-SCI population studies, and studies examining fractures at the time of acute SCI were excluded. References of included articles from the original search and task force and external submissions yielded two additional articles that were included in the review after voting by task force members. Data extraction was performed by four task force members using a data extraction form, glossary, and instructions created in Microsoft Excel. Quality assessment was performed by three methodologists using prespecified criteria.

SYNTHESIS

Twenty-three articles were included. Use of surgery to treat LE fractures in chronic SCI has increased, though nonoperative management was still more frequently reported. Regardless of type of management, amputations, nonunion/malunion, and pressure injuries were among the most commonly reported complications. Functional and quality of life outcomes were less frequently reported.

CONCLUSIONS

There is insufficient evidence to support operative versus nonoperative management as best practice for management of LE fracture of SCI. Existing literature was limited by small sample sizes, lack of randomization or matched study designs, significant heterogeneity in populations and treatment strategies studied, and variability in defining and reporting outcomes of interest. The field would benefit from future research to address study design issues and standardization of outcome reporting to facilitate comparison of outcomes of operative versus nonoperative management.

Prevention and management of osteoporosis and osteoporotic fractures in persons with a spinal cord injury or disorder: A systematic scoping review

Objectives: The primary objective was to review the literature regarding methodologies to assess fracture risk, to prevent and treat osteoporosis and to manage osteoporotic fractures in SCI/D.Study Design: Scoping review.Settings/Participants: Human adult subjects with a SCI/D.Outcome measures: Strategies to identify persons with SCI/D at risk for osteoporotic fractures, nonpharmacological and pharmacological therapies for osteoporosis and management of appendicular fractures.Results: 226 articles were included in the scoping review. Risk of osteoporotic fractures in SCI is predicted by a combination of DXA-defined low BMD plus clinical and demographic characteristics. Screening for secondary causes of osteoporosis, in particular hyperparathyroidism, hyperthyroidism, vitamin D insufficiency and hypogonadism, should be considered. Current antiresorptive therapies for treatment of osteoporosis have limited efficacy. Use of surgery to treat fractures has increased and outcomes are good and comparable to conservative treatment in most cases. A common adverse event following fracture was delayed healing.Conclusions: Most of the research in this area is limited by small sample sizes, weak study designs, and significant variation in populations studied. Future research needs to address cohort definition and study design issues.

Surgical management of lower limb fractures in patients with spinal cord injury less associated with complications than non-operative management: A retrospective series of cases

OBJECTIVES

To evaluate the difference in terms of overall complications between surgical and non-surgical management of lower limb fractures in patients with chronic spinal cord injury (SCI).

DESIGN

A 13-year retrospective study including patients with chronic spinal cord lesion admitted for sublesional lower limb fractures.

SETTING

University hospital SCI reference departments (Rehabilitation department and orthopedic department).

PARTICIPANTS

Forty patients with SCI were included, 24 men and 16 women. Fifty-six distinct fracture occurrences were responsible for a total of 59 lower limb fractures. We compared the number of overall complications between surgical and non-surgical management of fractures.

RESULTS

Non-surgical management was realized for 19 fractures and surgery for 40. Characteristics of operated and non-operated patients at the time of each fracture occurrence did not differ concerning age (P = 0.430), sex (P = 0.890), lesion levels (P = 0.410) and AIS classification (P = 0.790). Data analysis highlighted 20 complications directly due to the fracture site for 16 distinct fractures. Seven medical complications were found in 5 distinct fracture events. Only 10 (25.0%) of 40 surgical managements had at least one medical or post-surgical complication, whereas 12 (63.2%) of 19 non-operative managements had at least one complication. Therefore, the overall rate of complications was significantly higher after non-surgical treatment (P = 0.044).

CONCLUSION

Lower extremity fractures due to osteoporosis in patients with SCI are responsible for local and general complications. When possible, surgery may be the best management to propose because of fewer overall complications.

Management of Lower Extremity Long-bone Fractures in Spinal Cord Injury Patients

The AO classification system, used as a guide for modern fracture care and fixation, follows a basic philosophy of care that emphasizes early mobility and return to function. Lower extremity long-bone fractures in patients with spinal cord injury often are pathologic injuries that present unique challenges, to which the AO principles may not be entirely applicable. Optimal treatment achieves healing without affecting the functional level of the patient. These injuries often result from low-energy mechanisms in nonambulatory patients with osteopenic bone and a thin, insensate soft-tissue envelope. The complication rate can be high, and the outcomes can be catastrophic without proper care. Satisfactory results can be obtained through various methods of immobilization. Less frequently, internal fixation is applied. In certain cases, after discussion with the patient, amputation may be suitable. Prevention strategies aim to minimize bone loss and muscle atrophy.