Orthopedics

Feature Article 

Treatment of Lower-extremity Long-bone Fractures in Active, Nonambulatory, Wheelchair-bound Patients

Michelle T. Sugi, MD; Roy Davidovitch, MD; Nicole Montero, MD; Tamar Nobel, BA; Kenneth A. Egol, MD

Abstract

A retrospective review of surgically treated lower-extremity long-bone fractures in wheelchair-bound patients was conducted. Between October 2000 and July 2009, eleven lower-extremity fractures in 9 wheelchair-bound patients underwent surgical fixation. The Short Musculoskeletal Function Assessment, Short Form, and Spinal Cord Injury Quality of Life questionnaires were used to assess functional outcome.

Mechanism of injury for all patients was a low-energy fall that occurred while transferring. Four patients who sustained a distal femur fracture, 1 patient who sustained a distal femur fracture and a subsequent proximal tibia fracture, and 1 patient who sustained a proximal third tibia shaft fracture underwent open reduction and internal fixation with plates and screws. Three patients with 4 midshaft tibia fractures underwent intramedullary nailing.

At last follow-up, all 9 patients had returned to their baseline preoperative function. Quality of life was significantly higher (P<.01) than the Spinal Cord Injury Quality of Life questionnaire’s reference score. Self-reported visual analog scale pain scores improved significantly from time of fracture to last follow-up (P=.02). All fractures achieved complete union, and no complications were reported. This study’s findings demonstrate that operative treatment in active, wheelchair-bound patients can provide an improved quality of life postinjury and a rapid return to activities.

Drs Sugi and Montero and Ms Nobel are from the Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, and the Department of Orthopaedic Surgery, Jamaica Hospital Medical Center, Jamaica, and Drs Davidovitch and Egol are from the Department of Orthopaedic Surgery, New York University School of Medicine, New York, New York.

Drs Sugi, Davidovitch, Montero, and Egol and Ms Nobel have no relevant financial relationships to disclose.

Correspondence should be addressed to: Kenneth A. Egol, MD, New York University School of Medicine, 301 E 17th St, Ste 1402, New York, NY 10003 (kenneth.egol@nyumc.org).

Abstract

A retrospective review of surgically treated lower-extremity long-bone fractures in wheelchair-bound patients was conducted. Between October 2000 and July 2009, eleven lower-extremity fractures in 9 wheelchair-bound patients underwent surgical fixation. The Short Musculoskeletal Function Assessment, Short Form, and Spinal Cord Injury Quality of Life questionnaires were used to assess functional outcome.

Mechanism of injury for all patients was a low-energy fall that occurred while transferring. Four patients who sustained a distal femur fracture, 1 patient who sustained a distal femur fracture and a subsequent proximal tibia fracture, and 1 patient who sustained a proximal third tibia shaft fracture underwent open reduction and internal fixation with plates and screws. Three patients with 4 midshaft tibia fractures underwent intramedullary nailing.

At last follow-up, all 9 patients had returned to their baseline preoperative function. Quality of life was significantly higher (P<.01) than the Spinal Cord Injury Quality of Life questionnaire’s reference score. Self-reported visual analog scale pain scores improved significantly from time of fracture to last follow-up (P=.02). All fractures achieved complete union, and no complications were reported. This study’s findings demonstrate that operative treatment in active, wheelchair-bound patients can provide an improved quality of life postinjury and a rapid return to activities.

Drs Sugi and Montero and Ms Nobel are from the Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, and the Department of Orthopaedic Surgery, Jamaica Hospital Medical Center, Jamaica, and Drs Davidovitch and Egol are from the Department of Orthopaedic Surgery, New York University School of Medicine, New York, New York.

Drs Sugi, Davidovitch, Montero, and Egol and Ms Nobel have no relevant financial relationships to disclose.

Correspondence should be addressed to: Kenneth A. Egol, MD, New York University School of Medicine, 301 E 17th St, Ste 1402, New York, NY 10003 (kenneth.egol@nyumc.org).

The surgical indications and functional outcomes of long-bone fractures in ambulatory patients have been well established. However, the same fractures in wheelchair-bound patients have been poorly studied. Operative and nonoperative treatments have been advocated in the past, although the literature provides no clear consensus on management. The inability to bear weight and chronic wheelchair dependence result in decreased bone mineral density in these patients and places them at high risk for pathologic fractures.1 Further complicating the management of these patients are their unique comorbidities, including a negative nitrogen balance, malnutrition, skin insensitivity, and autonomic dysreflexia.2 Thus, the evaluation of long-bone fractures in wheelchair-bound patients entails a comprehensive assessment of not only the acute fracture, but also the patient’s baseline impairment preinjury, comorbidities, and available support system.

Traditional nonoperative management of fractures in these patients has included pillow splints, bracing, skeletal traction, and casting.3–6 These nonoperative treatment modalities require frequent skin checks to avoid the increased risk of decubitus ulcers, significant limitation of activities of daily living, and a limited ability for transferring. Nonoperative treatment has resulted in complication rates ranging from 19% to 42% and often involves numerous doctor office visits and constant nursing care.1,4 Complications that commonly arise with nonoperative treatment include decubitus ulcers, residual hip and knee stiffness, loss of reduction, nonunion, and malunion.7

Some studies recommend aggressive treatment of lower-extremity fractures in certain subgroups of paraplegics, particularly in wheelchair athletes, patients for whom loss of joint motion will impair function and performance, and patients who suffer autonomic dysreflexia associated with the fracture.4 Young, active, wheelchair-bound patients are often functional, employed, and integrated members of society, and as such have high expectations following traumatic injury. To date, no study has addressed the quality of life and functional outcomes of lower-extremity fractures in young, active paraplegics. The purpose of this study was to report on 1 surgeon’s experience with wheelchair-bound patients who underwent operative stabilization of lower-extremity long-bone fractures, with particular attention paid to patient-reported functional outcomes and complications.

Materials and Methods

This study was a retrospective review of a single surgeon’s database conducted at affiliated centers of a large, urban academic hospital. Between October 2000 and July 2009, one surgeon (K.A.E.) treated 11 lower-extremity long-bone fractures in 9 wheelchair-bound patients with surgical fixation. No patient was treated with postoperative immobilization. Written and institutional review board approved consent were obtained from all patients who met inclusion criteria and agreed to the use of their personal data for research purposes. Inclusion criteria included age older than 18 years, a long-bone fracture of the lower extremity occurring in a previously wheelchair-bound patient, and operative treatment of the fracture.

At enrollment, a series of standard radiographs were obtained of the affected extremity. A complete history and physical examination were performed, and the soft tissue envelope and neurovascular status were assessed. Trained researchers obtained demographic information, such as age, sex, fracture type, injury information, history of wheelchair dependence, and baseline functional questionnaires. The Short Musculoskeletal Function Assessment (SMFA),8 Short Form (SF-36)9 and Spinal Cord Injury Quality of Life (SCI-23)10 questionnaires were used to assess functional outcome. Pain was assessed via a visual analog scale (VAS) (range, 0–10). Operative data, including fracture pattern, implant type, and any soft tissue procedures, were extracted from patients’ records. Fractures were classified according to McMaster classification1: type I, acute (occurring at the time of spinal cord injury); type II, pathologic (chronic spinal cord injured patients with low-energy fractures in osteoporotic bone); and type III, traumatic (chronic spinal cord injured patients with high-energy fractures in relatively normal bone). Fractures were also classified according to the Orthopaedic Trauma Association (OTA) classification based on initial radiographs.11

This cohort of patients was treated with standard implants and techniques used in ambulatory patients. Intramedullary nails and locked plates were used in the recommended fashion based on fracture location and pattern and bone quality. Anesthesia was general or spinal based on patient and anesthesiologist preference and the underlying medical conditions of each patient.

Patients were seen by their treating surgeon, and data were collected by an independent, trained researcher (M.T.S.) at latest follow-up or over the telephone. Complication development was documented and recorded. Follow-up examinations were conducted at standard postoperative intervals and included documentation of pain; lower-extremity joint range of motion; follow-up SMFA, SF-36, and SCI-23 scores; and a standard series of radiographs of the affected extremity. Radiographs were examined for alignment and fracture healing.

The SMFA questionnaire is calculated by 2 parts: the dysfunction index and the bother index. The dysfunction index comprises 34 items that assesses patients’ perceptions of their functional performance. The bother index has 12 items that allow patients to assess how much they are bothered by problems in broad functional areas, such as recreation and leisure, sleep and rest, work, and family.8 Higher scores indicate poorer function. The SCI-23 was used as a specific measure of health-related quality of life and consists of 3 factors: (1) problems (assessed via questions regarding perceptions of physical dependency, complications, and social stigma); (2) function (covers limitation in mobility, body care and movement, and social interaction); (3) depression (reflects distress and depressive symptoms); and (4) global rating (overall quality of life measured by a single standardized question and compared with reference values from the general population sample studied by Kreuter et al12).10

Statistical Analysis

Patient data were analyzed to determine the association between variables and outcomes using the Student’s t test for continuous variables and the Z-test for reference score comparison. Significance was set at P<.05.

Results

Average patient age was 54 years (range, 33–72 years). Five patients were women and 4 were men. Average follow-up was 28 months (range, 6–108 months). Average length of nonambulatory status at time of fracture was 20 years (range, 5–48 years). All patients were wheelchair bound at the time of injury; 7 patients were paralyzed by a spinal cord injury and 2 were wheelchair bound due to multiple sclerosis.

The mechanism of injury was similar for all patients. Eleven (100%) fractures occurred in 9 patients during a low-energy fall while transferring (McMaster type II). Seven fractures were initially treated nonoperatively by outside physicians (average time to surgery, 38 days), and 4 fractures were operated on acutely (average time to surgery, 11 days). Two of these patients were treated following their initial fracture for a subsequent contralateral lower-extremity fracture (average time from index surgery, 4 months). Average length of hospitalization for all 11 fractures was 3.3 days (range, 1–6 days), with a median length of stay of 2 days. The majority (67%) of patients had some form of inpatient, postoperative physical therapy for transfer training.

Four patients who sustained a distal femur fracture (OTA 33) (Figures A, B), 1 patient who sustained a distal femur fracture followed by a subsequent contralateral proximal tibia fracture (OTA 41), and 1 patient who sustained a proximal-third tibia shaft fracture (OTA 42) underwent open reduction and internal fixation (ORIF) with locked plates and screws (Figures C, D). Three patients with 4 mid-shaft tibia fractures (OTA 42) underwent intramedullary nailing. No concomitant soft tissue procedures were performed in any patient, and all injuries were closed.

Preoperative anteroposterior (A) and lateral (B) radiographs of the knee of a 44-year-old man with a 17-year history of wheelchair dependence. The patient presented 6 weeks after injury with gross motion at the fracture site and reported pain related to muscle spasms and inability to transfer. Postoperative anteroposterior (C) and lateral (D) radiographs of the knee after treatment with plate and screw fixation of the distal femur. The patient had immediate improvement of function and return to independence.

Figure: Preoperative anteroposterior (A) and lateral (B) radiographs of the knee of a 44-year-old man with a 17-year history of wheelchair dependence. The patient presented 6 weeks after injury with gross motion at the fracture site and reported pain related to muscle spasms and inability to transfer. Postoperative anteroposterior (C) and lateral (D) radiographs of the knee after treatment with plate and screw fixation of the distal femur. The patient had immediate improvement of function and return to independence.

All 9 patients had returned to at least their baseline preinjury function as measured by the SMFA dysfunction and bother scores (Table). No significant differences existed in improvement of follow-up SMFA dysfunction scores for patients who were treated acutely with surgical management vs those who were originally treated with nonoperative management (P=.36). Comparison of pre- vs postoperative SMFA dysfunction scores for acutely managed patients (P=.78) and initial nonoperative patients (P=.80) demonstrated no significance (Table). Five patients returned to their preinjury employment, 3 returned to retirement, and 1 remained unemployed.

Baseline and Follow-up VAS Pain and SMFA Scores

Table: Baseline and Follow-up VAS Pain and SMFA Scores

Average self-reported VAS pain scores improved significantly from 3.09 preoperatively to .22 at latest follow-up (P=.02) as measured by the visual analog scale. As measured by the SCI-23 global rating score, overall quality of life at latest follow-up was 83.3 points (range, 67–100), which is significantly higher (P<.01) than the questionnaire’s reference score of 69.8 points as measured in a general population sample studied by Kreuter et al.12

Qualitatively, all patients reported satisfaction with the results of their treatment, and 100% reported that they would undergo the same procedure if they had to make the decision again. All fractures treated achieved unison at an average of 12 weeks (range, 8–20 weeks) postoperatively. This small patient cohort had no intra- or postoperative complications. No wound infections occurred in this series.

Discussion

The reported rates of fractures in paraplegic and tetraplegic patients range from 1% to 20%.3,6,13–15 The majority (97%) of these fractures are lower-extremity fractures, with tibia fractures occurring more frequently than femoral or ankle fractures.16 Historically, nonoperative management of long-bone fractures in the lower extremities of wheelchair-bound patients has been advocated as the optimal treatment.1,3,17 Authors advocating against operative treatment reason that an increased risk of osteomyelitis, urinary tract infection, contracture, and infection exists with ORIF in this population.3,17 Other authors have argued that ORIF should be an option for paraplegic patients on an individualized basis, primarily to allow for early rehabilitation.1,4,18,19 Currently, no clear consensus exists on how to approach these injuries, and knowledge regarding surgical outcomes is limited.

The current study found that independent wheelchair-bound patients who underwent surgical stabilization of their lower extremity long-bone fractures achieved excellent postoperative results. Short Musculoskeletal Function Assessment, SCI-23, and VAS pain scores all improved and returned to baseline function. These patients also had a reasonably short hospital length of stay, did not require secondary procedures, and were able to return to their preinjury job description on achieving union. The SMFA dysfunction and bothersome scores for these patients not only returned to baseline, but also exceeded baseline scores. Although no literature describes such a phenomenon, once healing occurs, patients reported improved function and satisfaction on the SMFA compare with the recent, acute injury status.

The current findings are supported by Chin et al,20 who reported that retrograde intramedullary nailing of femoral shaft or supracondylar fractures in nonambulatory patients allowed for fracture healing and rapid return to their previous level of function, without complications of malunion, nonunion, shortening, or infection.20 Cass and Sems21 reported 25 myelopathic patients (29 fractures) who sustained a supracondylar femur fracture (OTA 33). Their findings demonstrated that the 17 patients treated with plates or intramedullary rods had higher union rates and fewer skin and wound complications compared with the 12 patients treated nonoperatively. The authors recommended that surgeons consider operative treatment as an option in the management of distal femur fractures in nonambulatory, myelopathic patients; however, the study did not address quality of life or functional assessments.21

In a case report by Ruffing et al,22 excellent clinical and radiologic results were achieved in a 59-year-old wheelchair-bound man who underwent minimally invasive elastic intramedullary nailing for a lower-extremity fracture. Another study by Meiners et al23 retrospectively evaluated 55 lower-extremity fractures in 44 patients with chronic spinal cord injuries who were managed surgically. The authors found that for 53 of the 55 fractures, the patients regained their normal level of independence.23 Another study that examined 21 patients with an average 15-year history of chronic spinal cord injury demonstrated that operative fixation of lower-extremity fractures with a ring fixator resulted in fewer complications and improved range of motion compared with conservative management results in the literature.23 Although patients in the study experienced superior results with the external fixator compared with nonoperative management, the bulky fixator remained on the patients for an average of 68 days, and mean hospital stay was 76 days.23

To the current authors’ knowledge, this is the first study to examine quality of life and functional outcomes of operative treatment of chronic spinal cord–injured or wheelchair-bound patients. Although the quality-of-life measurement was limited in that it was compared with a younger reference population sample that included patients with other types of chronic injuries,12 the qualitative self-reports obtained from the patients highlighted the relatively high quality of life score calculated. Nonetheless, the small sample size, heterogeneous treatment modalities, and retrospective nature of the analysis present challenges to the conclusion.

In the authors’ opinion, the goal of operative treatment in young, active, independent, wheelchair-bound patients is to obtain early fracture stabilization, improve self-transferring and rehabilitation, and decrease hospitalization and nursing care. Operative stabilization of these fractures in this patient population precludes the need for prolonged casting or splinting, which allows for an earlier wheelchair return and thus an earlier return to independence and employment.

Conclusion

This study’s findings demonstrate that operative treatment in active, wheelchair-bound patients is safe and can provide an improved postinjury quality of life; rapid return to activities, rehabilitation, and preinjury function; and significantly less pain compared with baseline.

References

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Baseline and Follow-up VAS Pain and SMFA Scores

OutcomeMean Points±SD
P
BaselineFollow-up
VAS paina
  All patients3.09±3.30.22±.67.02
  Acute treatment3.00±2.76.33±.82.05
  Initial nonoperative treatment4.67±4.510±0NA
SMFA dysfunctionb
  All patients42.13±12.8640.58±14.57.80
  Acute treatment44.12±16.0243.07±13.69.78
  Initial nonoperative treatment39.15±6.9936.21±9.37.80

10.3928/01477447-20120822-25

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