Acute Lower Extremity Fracture Management in Chronic Spinal Cord Injury 2022 Delphi Consensus Recommendations

JBJS Open Access, 2023 · DOI: http://dx.doi.org/10.2106/JBJS.OA.21.00152 · Published: January 1, 2023

Spinal Cord Injury Research Methodology & Design Musculoskeletal Medicine

Simple Explanation

This clinical practice guideline (CPG) focuses on the treatment of acute lower extremity fractures in individuals with chronic spinal cord injuries (SCI). It considers both operative and nonoperative management approaches. The guideline development involved a systematic review, expert opinions, and the GRADE system to rate evidence quality and recommendation strength. It emphasizes shared decision-making between patients and providers. Key areas covered include acute fracture treatment, the role of physical therapy, and management of post-fracture complications. The goal is to help patients return to their pre-fracture functional level.

Study Duration

Not specified

Participants

Multidisciplinary expert panel consisting of orthopaedic surgeons, physiatrists, physical therapists, health service and clinical researchers, an endocrinologist, a rheumatologist, and a hematologist

Evidence Level

GRADE system used to determine the quality of evidence

Key Findings

1
Shared decision-making between patient and provider is recommended for definitive fracture management. Patients should be educated regarding the risks and benefits of both operative and nonoperative approaches.
2
Early consultation with orthopaedic surgeons and engagement of multidisciplinary teams is recommended upon identification of a lower extremity fracture.
3
The guideline provides specific recommendations for operative and nonoperative management based on fracture location (hip, femur, tibia/fibula, ankle, foot).

Research Summary

This guideline provides recommendations for acute lower extremity fracture management in patients with chronic SCI, emphasizing education, shared decision-making, and multidisciplinary care. The role of surgical treatment is evolving, with considerations for improved surgical techniques and implant technology, aiming for early mobilization and reduced complications. Prevention of fractures and related complications, such as pressure injuries and nonunions, is crucial, with consideration of bone-healing adjuvants and thromboprophylaxis.

Practical Implications

Clinical Practice

The guideline offers evidence-based recommendations to standardize and improve the quality of care for individuals with SCI who experience lower extremity fractures.

Rehabilitation

Highlights the importance of early involvement of physical therapists and other rehabilitation specialists to optimize functional outcomes and prevent complications.

Future Research

Identifies the need for further research comparing different surgical procedures and treatment strategies specific to the SCI population.

Study Limitations

1
The guidelines are largely based on expert opinion due to a lack of high-quality evidence specific to the SCI population.
2
Many surgical recommendations are informed by literature from the able-bodied population.
3
Future updates may be necessary as more evidence becomes available.

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