Para/Medic: Fracture Risk and Treatment Options with SCI


BobOct14

Q. I’m 57 years old, in my 40th year as a T12 complete para. Five weeks ago I was in my chair getting dressed with my left leg crossed and resting on my right knee while I put on my shoe. When I leaned forward to tie the shoe, I heard a dull pop and my left knee dropped. Within moments my mouth went dry and my heart started racing — I knew I had broken my left hip.

At the emergency room, X-rays confirmed I had broken my left trochanter (the bone that leads from the femur to the ball that fits in the socket) in two places. An orthopedist said my fracture would heal on its own if I wore an orthotic brace and kept my leg quiet for three to four months. Another orthopedist came in later and said he could stabilize it by inserting a “long intramedullary nail” (long rod) the length of my femur and running a sliding hip screw through an angled hole near the top of the IM nail to secure the trochanter and hip ball.  


I opted for surgery and was up in my chair and home, albeit slow and careful, in five days. Unfortunately, within a month the sliding hip screw pulled out of the hip ball and the surgeon had to remove it. The good news is he says everything is lined up and lots of new bone has already grown in. The plan now is to keep the hip supported with pillows while lying down and carefully supported while transferring — he is hopeful it will finish healing on its own within a month. With SCI, how does one know which route to choose when healing a fracture?

   — Darren

A.
Darren, excellent question. According to a 2005 research publication, “Pathologic Extremity Fracture Care in Spinal Cord Injury,” people with SCI have a 40 percent incidence of fractures to the lower extremities (hip and leg). The article explains that the rate is probably much higher because fractures treated at non-SCI centers are not reported.

The high fracture rate stems from osteoporosis caused by chronic SCI, says Dr. Douglas Garland, an orthopedic surgeon and former director of neurotrauma at Rancho Los Amigos Rehab Center. Garland, who has researched SCI and osteoporosis for the past 25 years, explains that the longer you have had SCI, the more fragile the bones in your lower extremities become. He has created a formula to determine the estimated bone strength — measured in bone mineral density — in your lower extremities based on your age and how long you have been injured (see Resources). The average person with SCI loses 28 percent of their BMD within the first 16 months of injury. Around that point, BMD loss slows down but continues at a rate of 1 percent per year. However, the good news is BMD in the lumbar spine rebuilds, reaching normal within 10 years of injury. In addition, for reasons unknown at this time, 30 percent of people with SCI gain back much of their BMD in other areas as well.

Osteoporosis is diagnosed when you’ve lost 32 percent BMD, which puts you in the “fracture threshold” (where a minor fall or missed transfer can cause a break). A 50 percent loss of BMD is considered the “fracture breakpoint,” where minor incidents like stretching or even getting a limb caught in the covers while rolling over in bed can cause a fracture.

It is important for a person to have a basic knowledge of fracture management with SCI because this is an unfamiliar area for many doctors and orthopedists, says Garland. In the event of a fracture, referring the treating physician to “Pathologic Extremity Fracture Care

[in SCI]” is a good idea, says Garland.

Although every fracture is unique, Garland says most non-displaced fractures (when the bone is still lined up) can be treated non-operatively with pillow splints, immobilizers or careful bracing, sometimes custom made. Also, he says it is important to be sure they are well padded and can be opened for skin inspection. “In the case of femur and some tibial fractures, intramedullary nails can often surgically fix the fracture. This is preferred over screws and plates because screws can pull out of osteoporotic bone.”

For a broken hip, the first line of treatment is still non-surgical. If the fracture stays in alignment, it can be supported with an orthopedic brace and/or pillows while healing. The next option is securing the fracture with surgical screws — if this is done, it is crucial to avoid stress on the hip, especially any pulling, like letting the leg hang during a transfer. Not only can this pull screws out of osteoporotic bone, but muscle spasticity can stress screws and cause the same result. Spasms can sometimes be quieted by injecting Botox into the spastic muscles.

Treatment for a failed attempt at healing a hip fracture has changed. “The old fashioned rule has been don’t do a hip prosthesis (artificial hip) because the risk of post-op dislocations was too high,” says Garland. A girdlestone surgery — removing the ball, smoothing the trochanter, and pulling muscle around the end of the femur to create a cushion of scar tissue — was the only option left. This is a serious surgery best done by a surgeon experienced in the procedure.

However, improved technique and prosthetics have now made artificial hips an option for people with SCI. “A prosthetic hip in a person with SCI is now an option, assuming the hip capsule is in good condition,” says Garland. “You can do two types of repair — the cup and ball, or just the ball. The ideal way to do a prosthetic in a person with SCI is just the ball, (endoprosthesis — where the ball and stem go into the femur).” Surgeons are now doing the hip anteriorly (through the front of the hip capsule) versus posteriorly (through the rear of it). This makes such a big difference because the incision in the hip capsule, even after it has healed, is an area of weak scar tissue that can stretch, and when that happens, the hip can dislocate. The usual area of stress for an artificial hip is on the posterior part of the capsule. By doing an anterior incision, the area of the capsule (posterior) that is under the most stress is not compromised.

“Another improvement is larger endoprosthesis balls,” says Garland. A larger head means a tighter fit in the socket, which makes it more difficult to dislocate. The combination of anterior incision and larger prosthetic head means good range of motion and reduced incidence of dislocation.

An option that is frequently discussed in SCI chat rooms is an artificial hip with artificial socket that has a ‘retaining’ ring to prevent dislocation.  Garland recommends an in-depth discussion with an orthopedic surgeon before doing this option because the retaining ring limits range of motion. Be sure to ask how much range of motion your leg will have with a retaining ring, especially because without sensation, if the leg moves beyond the built-in stop, it can rip out the entire cup.

In the case of repairing a hip fracture, Garland reiterates the options in order of preference:
1. Manage with pillows and or splinting.
2. Repair with surgical screws.
3. Prosthetic hip (endoprosthesis) only. “If the endoprosthesis fails, you can always go back and add a prosthetic cup.  And if all of that fails, you still have the option of a girdlestone.”

Resources
• “Bone Impairment and Spinal Cord Injury”: cirrie.buffalo.edu/encyclopedia/en/article/108/
• “Osteoporosis Update: Avoiding the Breaks”: www.newmobility.com/2009/12/osteoporosis-update/
• “Pathologic Extremity Fracture Care in Spinal Cord Injury”: archive.scijournal.com/doi/abs/10.1310/NNXN-FT78-EAC6-A6EJ


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