Bone Complications

Sublesional osteoporosis is a disease process characterized by excessive bone resorption and regional declines in bone mineral density (BMD) of the hip and knee region after spinal cord injury (SCI), which reduces bone quantity and results in an increased propensity for lower extremity fragility fracture. Twenty-five to forty-six percent of persons living with chronic SCI develop fragility fractures secondary to sublesional osteoporosis [1, 2].  The incidence is probably higher because not all fractures are recognized or reported.

Lower extremity fragility fractures after SCI are most commonly due to a torsional stress on the long bones of the legs during a transfer or a compressive force during a low velocity fall from a wheelchair.  There is overwhelming evidence that supports the importance of addressing bone health issues early after a SCI.  The distal femur and proximal tibia are most at risk, consistent with site-specific decreases in bone mineral density around the knee [3].  A single fragility fracture will often result in a cascade of events that ultimately increases morbidity for patients with SCI due to the complications of fracture immobilization (i.e., heel ulcer or deep venous thrombosis) and decreases their functional abilities due to immobilization devices. Patients often require increased attendant care services for three to six months time during fracture healing.  Fragility fractures after SCI frequently result in delayed union, non-union or mal-union; in extreme cases, lower extremity amputation may result [4].

Heterotopic Ossification is a common complication of traumatic SCI, with a prevalence ranging from 5 to 50% [5-7]. The progression of heterotopic ossification may lead to decreases in the range of motion and anchylosis, which in turn may negatively impact on rehabilitation [8]. The most affected joints are the hips (60%-70%) and knees (20%-30%) [5].  In its more advanced stages, it can become an extremely disabling condition [9].

BONE HEALTH RESOURCES

Clinical Guidelines for the Management of Healthy Bones after SCI can be found at: Fragments 1.0

References:

1. Vestergaard P, Krogh K, Rejnmark L, Mosekilde L. Fracture rates and risk factors for fractures in patients with spinal cord injury. Spinal Cord 1998;36:790-6.

2. Comarr AE, Hutchinson RH, Bors E. Extremity fractures of patients with spinal cord injuries. Am J Surg 1962;103:732-9.

3. Ashe MC, Craven C, Krassioukov A, Eng JJ (2010). Bone Health Following Spinal Cord Injury. In: Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Mehta S, Sakakibara BM, editors. Spinal Cord Injury Rehabilitation Evidence. Version 3.0 Vancouver: p 1-26.

4. Kiratli BJ, Smith AE, Nauenberg T, Kallfelz CF, Perkash I. Bone mineral and geometric changes through the femur with immobilization due to spinal cord injury. J Rehab Res Dev 2000;37:225-33.

5. Hernandez AM, Forner JV, de la Fuente T, Gonzalez C, Miro R. The para-articular ossifications in our paraplegics and tetraplegics: a survey of 704 patients. Paraplegia 1978;16:272-5.

6. Blane CE, Perkash I. True heterotopic bone in the paralyzed patient. Skeletal Radiol 1981;7:21-5.

7. Wharton GW, Morgan TH. Ankylosis in the paralyzed patient. J Bone Joint Surg [Am] 1970;52:105-12.

8. Freehafer AA, Yurick R, Mast W. Para-articular ossification in spinal cord injury. Med Services J 1966;22:471-8.

9. Coelho CV, Beraldo PS. Risk factors of heterotopic ossification in traumatic spinal cord injury. Arq Neuropsiquiatr 2009 67:382-7.

Page last updated May 14, 2013