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Bone Health

Fracture Risk Following SCI

The vast majority of current evidence supports the importance of addressing fracture risk after SCI since there is a higher incidence of fragility fractures in this population (Table 1). The majority of fragility fractures occur following transfers or activities that involve minimal or no trauma (Comarr et al. 1962; Ragnarsson & Sell; 1981; Freehafer 1995; Akhigbe et. al 2015) where the distal femur and proximal tibia (knee region) are most at risk.

Recent findings from review studies in veterans (n=12,162) with SCI have found that 82.6% of all fractures were at the tibia/fibula, femur or hip (Fig 1). Further, individuals with SCI were less likely to receive surgical intervention, than people without SCI, although those with SCI who have surgery did not have increased mortality or adverse event rates (Bishop et. al, 2013; Bethel et. al, 2015). Delayed fracture union is common after SCI (Grassner et al. 2017). Following a fracture there is a five-year increased risk of mortality (Pelletier et al. 2014; Carbone et al. 2014).

Figure 1. Many of the fractures that individuals with SCI sustain occur in the region of the metaphysis and epiphysis. Source: http://sci.washington.edu/info/forums/reports/osteoporosis.asp#dx

Risk factors for fragility fracture after SCI include:

  • Sex
  • Age at injury
  • Time Post-Injury
  • Type of impairment
  • Low BMI
  • Low knee region BMD, and
  • Use of anticonvulsants, heparin, or opioid analgesics.

Women are at greater risk compared to men (Vestergaard et al. 1998; Lazo et al. 2001; Nelson et al. 2003; Garland et al. 2004). Increasing age and longer TPI (Frisbie 1997; McKinley et al. 1999; Garland et al. 2004; Garland et al. 2005) increases fracture risk which rises significantly at 10 years post-injury. Further, people with paraplegia have more fractures (Frisbie 1997) and those with complete injuries have greater bone mass loss compared with those with incomplete injuries (Garland et al. 2004; Garland et al. 2005).

A number of concurrent medications a patient is taking can also decrease or substantially increase fracture risk. These include but are not limited to: heparin, benzodiazepines, anticonvulsants, proton pump inhibitors, selective serotonin reuptake inhibitors and opioid analgesics. In a large retrospective cohort study of men with chronic SCI (n=6969, ≥ 2 years post-injury), the use of thiazide-type diuretics was associated with a 25% reduction in the risk of lower extremity fragility fractures (Carbone et al. 2013c). In contrast, the use of heparin (HR 1.48, CI 1.20-1.83), opioid analgesics (HR 1.80, CI 1.57-2.06), or anticonvulsants (HR 1.35, CI 1.18-1.54), especially the benzodiazepine sub-class (HR 1.45, CI 1.27-1.65), was associated with an increased risk of lower extremity fragility fractures in men with chronic SCI (≥ 2 years post-injury) (Carbone et al. 2013a, 2013b). Men with chronic SCI are at a slightly increased risk of lower extremity fragility fractures when exposed to proton pump inhibitors (HR 1.08, CI 0.93-1.25), selective serotonin reuptake inhibitors (HR 1.05, CI 0.90-1.23), or thiazolidinediones (HR 1.04, CI 0.68-1.61) (Carbone et al. 2013a, 2013b). However, these drugs and a prior history of fragility fracture or a history of fracture in a parent are known risk factors for the development of osteoporosis in the general population, and should, therefore, be considered when assessing fracture risk in SCI patients.

First Author
Year
N
Age
Range in Years (Mean±SD)
Fractures Risk Factors
Comarr
1962
N = 1,363
Age – 19-58
109 post-SCI incident lower extremity fractures occurred among 81 out of 1363 participants with traumatic SCI (57% paraplegia, 75% complete). Most common fractures were distal femur (37%), proximal femur (11%) Motor complete SCI paraplegia
Ragnarsson
1981
Study 1
N = 578
Age = 4-77
33 lower extremity fractures occurred among 23 out of 578 participants (15 men and 8 women) with chronic SCI (78% paraplegia, 91% complete). Most common fractures were supracondylar fractures of femur (33%), femoral shaft (30%) and tibial shaft (18%) Motor complete SCI

Ragnarsson
1981
Study 2
N = 3,027
Age = 13-77

(National SCI Data Research Centre); 52 lower extremity fractures occurred among 44 out of 3027 participants (37 men and 7 women) with chronic SCI (70% paraplegia, 64% complete). Most common fractures were ankle (24%, tibial shaft (20%) and femoral neck (17%) N/A
Frisbie
1997
N = 120
Age = 20-77
103 fractures (82% lower extremity) occurred among 40 out of 120 men with chronic SCI (91% traumatic, 30% paraplegia, 80% complete). Most common fracture sites were hip, femoral shaft, supracondylar femur, and tibia.
Fracture incidence per age group:
– 15 fractures/1000 participants years (20-39 years)
– 31 fractures/1000 participants years (40-59 years)
– 46 fractures/1000 participants years (60-79 years)
Ageing; with fracture incidence rising with age
Vestergaard
1998
N = 438
Age = 10-80
Overall fracture rate among 438 participants (309 men and 129 women) with SCI (94% traumatic, 55% paraplegia, 68% complete) was 2%/year. cumulative fracture incidence=21% Women > men;
men with a family history of fracture;
TPI ≥3 years;
level of SCI (cervical lesions with more fractures)*
McKinley
1999
N = 20,804 population-based all ages
20,804 participants over a 20-year timeframeTotal number of participants involved in study: 1yr post-SCI, 6,776; 2yrs post-SCI, 5,744; 5 years post-SCI, 4,100; 10yrs post-SCI, 2,399; 15yrs post-SCI, 1,285; 20yrs post-SCI, 500
Prevalence of lower extremity fractures in women
1% (5 years post-SCI)
– 2% (10 years post-SCI)
– 3% (15 years post-SCI)
– 6% (20 years post-SCI)
Prevalence of lower extremity fractures in men
1% (5 years post-SCI)
– 1% (10 years post-SCI)
– 2% (15 years post-SCI)
– 2% (20 years post-SCI)
Women > men;
TPI
Lazo
2001
N = 41
Age = 56±13
41 men with traumatic or Ischemic chronic SCI (57% paraplegia, 93% complete)
26 fractures (82% lower extremity) in 14 participants
Most common fracture site was above knee (35%)
Low femoral neck BMD (OR = 2.1, 95% CI = 1.27-3.43; per t-score decrement)
Nelson
2003
N = 23
Age = 39-85
23 participants (22 men and 1 woman) with SCI (44% paraplegia) over 10 years (2.7% of the group). 31 fall-related fractures (97% lower extremity. Most common fracture sites were tibia/fibula (55%) and femoral fractures (35%) Falls among those age 39-59 years
Morse 2009b
N = 315
Age = 55.0±14.4
39 fractures occurred among 30 men with SCI (50% paraplegia, 83% motor complete) during the first-year post-injury. Most common fracture sites were tibia/fibula (47.5%), distal femoral metaphysis (20%) and proximal femur (15%) Motor complete SCI; post-injury alcohol consumption > 5 servings*/day
Garland
2004
N = 152
Age = 20-71
9 out of 152 participants with post-SCI fractures (130 men and 22 women) with SCI (54% paraplegia, 67% motor complete). TPI: 12.9 ± 9.3 (range: 1.1 to 44.4) years. Motor complete SCI; increasing age; low BMI
Zehnder
2004a
N = 98
Age = 18-60
39 fractures occurred among 15 paraplegic men with traumatic motor complete SCI. Overall fracture incidence was 2%/year. TPI strata;
1%/year < 1-year post-SCI
1%/year 1-9 years post-SCI
3%/year 10-19 years post-SCI
5%/year (20-29 years post-SCI)
Low knee region BMD;
Eser
2005
N = 99
Age = 19-83
21 out of 99 participants (89 men and 10 women) with traumatic motor complete SCI (72% paraplegia) with lower extremity fractures TPI;
trabecular vBMD less than:
114g/cm3 distal femur 4% site;
72g/cm3 distal tibia 4% site;
Garland
2005
N = 168
Age = 26-52
27 of 168 participants with chronic SCI (61% complete) with post-injury lower extremity fracture Low BMD <25kg/m2;
increasing age;
low BMI;
Carbone
2013a, 2013b
N = 7,447
Age = 58±13
892 out of 7447 men with chronic traumatic SCI (56% paraplegia, 37% complete) had incident lower extremity fragility fractures over 5 years (12% of the cohort) motor complete SCI;
use of anticonvulsants; (use of benzodiazepine or use of multiple anticonvulsants), heparin use,
opioid analgesia use 28mg of morphine equivalent
Tan et. al
2014
N = 27
Age = 21 – 64
27 men with chronic traumatic SCI
(70% paraplegia, 82% complete)
6/27 men with post-SCI osteoporotic fractures
Higher level of adiponectin among wheelchair users
Range of values 5657 ± 3003 (wheelchair users with history of fractures)
Akhigbe et. al
2015
N = 140
Age = 56.5±12
140 participants (137 men, 2 women, and 1 unknown) with chronic traumatic SCI (67% paraplegia, 51% complete) with 155 incident lower extremity fractures. Common fracture sites were tibia/fibula (54%) and femur (33%) Transfers account for 1/3 of fractures
Bethel et. al 2016
N = 22,516
Age = 55±13
3365 participants (3,246 men and 119 women) with chronic SCI and incident fractures (66% traumatic, 44% non-traumatic, 38% with paraplegia, 42% motor complete) A majority ((80%) were lower extremity fractures; tibia/fibula (26%), femur (18%), and the hip (13%) White race;
Traumatic etiology of SCI; paraplegia;
Motor complete SCI;
TPI;
Use of anticonvulsants,
Use of opioids
Use of benzodiazepines;
History of prevalent fractures; higher Charlson Comorbidity Index score;
Women aged ≥ 50 years

Fracture thresholds are values below which fragility fractures begin to occur, whereas fracture breakpoints are values below which the majority of fractures occur (Garland et al. 2005). Knee region areal BMD (aBMD) and volumetric (vBMD) thresholds for fracture and breakpoint have been identified (Mazess 1990; Eser et al. 2005; Garland et al. 2005). BMD thresholds are described on Table 2.

Name Value Definition
Fracture threshold ≤ 0.78 g/cm2 (aBMD)
< 114 mg/cm3 (vBMD-femur)
< 72 mg/cm3 (vBMD-tibia)

Knee region BMD values below which fragility fractures occur

Fracture breakpoint < 0.49 g/cm2 (aBMD)

Knee region BMD values at which the majority of fragility fractures occur

Column 1 Value 3 Column 2 Value 3 Column 3 Value 3
BMD = bone mineral density; aBMD = areal BMD; vBMD = volumetric BMD.
Reproduced from Craven BC, Robertson LA, McGillivray CF, Adachi JD (page 7).1 © 2009
Thomas Land Publishers, Inc. www.thomasland.com. Reprinted with permission.

We recommend documenting your patient’s fracture risk by completing the risk factor profile checklist (Craven et al. 2008; Craven et al. 2009). We propose that the presence of ≥ 3 risk factors implies a moderate fracture risk, and ≥ 5 risk factors implies a high fracture risk (Table 3).

Risk Factors
Age at Injury < 16 years
Alcohol Intake > 5 servings/day
Body Mass Index < 19
Duration of SCI ≥ 10 years
Woman
Motor Complete (AIS A-B)
Paraplegia
Family history of fracture in men
Anticonvulsant use (i.e., Tegretol, Depakote Gabapentin – Neurontin)
Spasticity Medication
Opioid analgesia use (≥28 mg morphine for 3 months)
Prior fragility fracture**
SSRI
PPI
Knee region BMD below the fracture threshold**
**The big 2**

Gap: Fracture Management After SCI

Source of evidence
At present, there are few studies describing optimal fracture management after SCI. A website with clinical consensus recommendations on Osteoporosis and Fractures in Persons with SCI can be found at: http://sci.washington.edu/info/forums/reports/osteoporosis.asp

Recognizing a fracture
A fracture may be evident if there was an incident involving a fall or torsion (twisting motion) of the legs. Symptoms of knee region fracture of the distal femur or proximal tibia may include any of the following:

  • Swelling, red or warm skin, pain, deformity, autonomic dysreflexia, or increased spasticity.

Management
Appropriate fracture management can reduce morbidity and mortality among patients. Here we suggest some principles of fracture risk management for people living with an SCI.
General principles include venous thromboembolism prophylaxis, bi- valving the cast or immobilization device, provision of calcium and vitamin D supplementation, and osteoporosis therapy to prevent a future fracture.
Venous thromboembolism prophylaxis with low molecular weight heparin or a direct oral anti-coagulant should follow the current prevention guidelines until the resumption of normal activity. Anti-embolic stockings or compression wraps can be used for those with regional and/or premorbid dependent edema.
Optimal dietary Calcium and vitamin D supplement intake should be encouraged. The dietary supplementation’s efficacy should be checked through serum 25-hydroxyvitamin D level, 30 days after initiating therapy to ensure values are within therapeutic range (>100 nmol/L) for the SCI population.
Osteoporosis therapy to prevent fracture should be considered early post-fracture.
Delayed and non-union fractures could be monitored using portable ultrasound systems.
Most of the injuries above the knee are treated operatively. Injuries below the knee could be managed using bivalve immobilization devices and casts with windows for the malleoli and heel to reduce the incidence of pressure injuries. There may be a need for an elevated leg rest for wheelchair; however, this could increase the risk of falling due to a forward shift in their centre of gravity.
When healing is completed, clinicians should work with patients to restore the range of motion of hip, knee and ankle.
Early recognition and management of tissue injury, persisting edema, and mood disorders can help to optimize fracture outcomes.

First Author
Year
N
Age
Range in Years (Mean±SD)
Fractures Risk Factors
Bethel et al.
2015
1281
56±12

1,281 men with traumatic chronic SCI (57% paraplegia, 54% complete) with 1,979 incident fractures consisting of 345 (17%) upper extremity fractures and1634(83%)lower extremity fractures. Most common upper-extremity fracture sites were the humerus (28%) and lower-extremity fracture sites were tibia/fibula (33%), femur (26%) and hip (16%)

Traumatic SCI-TPI>2 years

Bethel et al. 2015 compared results of incident fracture treatment (surgical vs. non- surgical) among male veterans with chronic SCI. The study comprised 1,979 incident fractures that occurred among 1281 veterans over 6 years. The majority of fractures occurred in lower extremities (~83%), and the majority of these fractures were treated nonsurgically (~90%). The authors reported that there was a significant difference in the level of injury and fracture treatment modality, surgery treatment being used more among individuals with paraplegia (p = 0.04). However, there were no significant fracture treatment-related differences in mortality rates.

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