Lower extremity fracture prevention and management in persons with spinal cord injuries and disorders: The patient perspective

Context/ObjectiveTo describe patient experiences with fracture prevention and management among persons with spinal cord injuries/disorders (SCI/D).DesignQualitative data collected via semi-structured telephone interviews.SettingVeterans Health Administration (VA) SCI/D System of Care.ParticipantsVeterans with SCI/D (n = 32) who had experienced at least one lower-extremity fracture in the prior 18 months.InterventionsN/A.Outcome MeasuresInterview questions addressed patients’: pre-fracture knowledge of osteoporosis and bone health, diagnosis and management of osteoporosis, history and experiences with fracture treatment, and post-fracture care and experiences.ResultsParticipants expressed concerns about bone health and fractures in particular, which for some, limited activities and participation. Participants recalled receiving little information from providers about bone health or osteoporosis and described little knowledge about osteoporosis prevention prior to their fracture. Few participants reported medication management for osteoporosis, however many reported receiving radiographs/scans to confirm a fracture and most reported being managed non-operatively. Some reported preference for surgical treatment and believed their outcomes would have been better had their fracture been managed differently. Many reported not feeling fully included in treatment decision-making. Some described decreased function, independence and/or participation post-fracture.Conclusion(s)Our results indicate that persons with SCI/D report lacking substantive knowledge about bone health and/or fracture prevention, and following fracture, feel unable and/or hesitant to resume pre-fracture participation. In addition, our findings indicate that individuals with SCI/D may not feel as engaged as they would like to be in establishing fracture treatment plans. As such, persons with SCI/D may benefit from ongoing discussions with providers about risks and benefits of fracture treatment options and consideration of subsequent function and participation, to ensure patients preferences are considered.     

Applications of complementary therapies during rehabilitation for individuals with traumatic Spinal Cord Injury: Findings from the SCIRehab Project

Objective: Evaluate the use of complementary therapies during rehabilitation for patients with traumatic spinal cord injury (SCI).

Design: Secondary analyses were conducted to identify the use and associated outcomes of complementary therapies provided by occupational therapists (OTs) and physical therapists (PTs) during rehabilitation from a public dataset.

Setting: Inpatient rehabilitation.

Participants: A public dataset composed of 1376 patients with SCI that were enrolled in a five-year, multi-center investigation, the SCIRehab Project. Secondary analyses focused on a subset of 93 patients (47 who received complementary therapy during treatment and 46 case-matched controls who received no complementary therapy).

Interventions: OTs and PTs recorded use of complementary therapies during sessions, including yoga, Pilates, tai chi, aromatherapy, relaxation techniques, imagery and other.

Outcome Measures: Pain interference, pain severity, mobility, and social integration.

Results: Three percent of participants received any complementary therapies. Patients who received complementary therapies showed greater reductions in pain severity from 6 months to 12 months relative to matched controls. Furthermore, the amount of time that patients received complementary therapies during physical therapy sessions was associated with reduced pain interference at 6 months and with reduced pain severity at the 6-month and 12-month follow-ups. Complementary therapy use was not associated with mobility or social integration.

Conclusion: The current study provides preliminary evidence documenting the limited use of complementary therapies in rehabilitation settings and highlights the opportunity for further research, particularly regarding pain-related outcomes.     

Therapists' Roles in Pressure Ulcer Management in Persons With Spinal Cord Injury

Background:

Among veterans with spinal cord injury (SCI), severe pressure ulcers (PrU) are treated by interdisciplinary rehabilitation teams in SCI units.

Method:

Cross-sectional survey administered to therapists attending a conference of the Therapy Leadership Council in SCI.

Participants:

Respondents included physical therapists (PTs; n  =  24) and occupational therapists (OTs; n  =  15).

Main Outcome Measurements:

Wound care practices as indicated by 75% or more of participants as “usual practice.”

Results:

In general, therapist involvement with wound care was initiated by physician order (eg, electrical stimulation) or postsurgery protocols. “Usual practice” after tissue healing included progressive range of motion; initial remobilization (first sitting after wound healing); progression of sitting time including assessment of skin tolerance; instruction in pressure relief maneuvers/techniques; and instruction in safe transfers. Practices in prevention of a new ulcer included education and evaluation of seating posture/positioning.

Conclusions:

Results indicate that centers may delegate responsibilities for management of ulcers differentially by discipline. A limitation was that we were unable to determine whether these centers were the same or different for OT and PT respondents. Although sample size was small and some sites had multiple respondents, the survey showed a growing role for OTs and PTs in PrU treatment. Because 75% of each discipline reported that there were usual practices, including patient education and remobilization protocols, this area requires further study to determine the clinical outcomes in terms of preventing PrUs and recurrence.     

Edema assessment and management practice patterns among hand therapists: Survey research

Study DesignSurvey research.IntroductionRecently, the lymphatic system's role in edema management has been reported; however, it is unclear how this evidence has translated into hand therapy practice.Purpose of the StudySurvey research was performed to explore edema education and management.MethodsA 22-question survey containing questions related to edema education and practice was administered to members of the American Society of Hand Therapists. Demographic data were obtained. Frequencies were examined using Chi-square and Fisher exact tests.ResultsA total of 436 members responded to the survey (92% occupational therapists [OTs]; 6% physical therapists [PTs]). Most hand therapists received edema education through on-the-job training and, or continuing education. PTs were more likely to learn the difference between acute, subacute, chronic edema (P < .01; 36% PTs, 17% OTs) and the role of the lymphatic system in edema management (P < .002; 36% PTs, 14% OTs) in entry-level education compared to OTs. OTs with an MS or OTD were more likely to learn the difference between acute, subacute, chronic edema (P < .001; 23% OTD, 24% MS, 10% BS) and the role of the lymphatic system in edema management (P < .004; 19% OTD, 19% MS, 7% BS) in entry-level education than BS-trained OTs. Duration and feel were common ways therapists assessed and identified differences in edema. Many therapists acknowledged the role of the lymphatic system in edema reduction, but responses lacked specificity.ConclusionThe survey results suggest most hand therapists learn edema management outside of academic programs, although this may be changing in OT with advancement of the entry-level degree.     

Physical therapy after spinal cord injury: A systematic review of treatments focused on participation

Abstract

Context

Over the last four decades, the focus of spinal cord injury (SCI) rehabilitation has shifted from medical management to issues that affect quality of life and community participation. Physical therapists (PTs) need to design and implement interventions that result in maximal participation to provide an individual with SCI an effective rehabilitation program.

Objective

The aim of this review is to assess the extent, content, and outcomes of physical therapy (PT) interventions focused on improving the participation of individuals with SCI.

Methods

A search was conducted in Medline, Embase, CENTRAL, CINAHL, PEDro, and PsycINFO. We included studies, of all designs, focused on improving the participation of individuals with SCI using PT interventions.The primary author and a reviewer independently selected articles for inclusion, assessed articles quality, and extracted the data.

Results

Five studies met the inclusion criteria. The interventions applied were 9- and 12-month body weight-supported treadmill training in two studies, a supervised 9-month exercise program, a 12-week home exercise program, and a 10-week multidisciplinary cognitive behavioral program for coping with chronic neuropathic pain. Four of five PT interventions positively impacted the individual's perceived participation and satisfaction with participation.

Conclusion

The body of research by PTs on interventions to improve participation is limited. PTs must document the effects of interventions with a valid outcome tool to enable more research that examines participation. Expanding participation research will allow PTs to meet the needs of individuals with SCI and identify what interventions best facilitate integration into the community.     

Ertapenem-associated neurotoxicity in the spinal cord injury (SCI) population: A case series

Objectives: The primary objective was to review the literature regarding methodologies to assess fracture risk, to prevent and treat osteoporosis and to manage osteoporotic fractures in SCI/D.

Study Design: Scoping review.

Settings/Participants: Human adult subjects with a SCI/D.

Outcome measures: Strategies to identify persons with SCI/D at risk for osteoporotic fractures, nonpharmacological and pharmacological therapies for osteoporosis and management of appendicular fractures.

Results: 226 articles were included in the scoping review. Risk of osteoporotic fractures in SCI is predicted by a combination of DXA-defined low BMD plus clinical and demographic characteristics. Screening for secondary causes of osteoporosis, in particular hyperparathyroidism, hyperthyroidism, vitamin D insufficiency and hypogonadism, should be considered. Current antiresorptive therapies for treatment of osteoporosis have limited efficacy. Use of surgery to treat fractures has increased and outcomes are good and comparable to conservative treatment in most cases. A common adverse event following fracture was delayed healing.

Conclusions: Most of the research in this area is limited by small sample sizes, weak study designs, and significant variation in populations studied. Future research needs to address cohort definition and study design issues.     

Physical activity promotion to persons with spinal cord injury by health and exercise professionals: A scoping review

Objectives:Health and exercise professionals (HEPs) are ideal promoters and valued messengers of physical activity (PA) information among persons with spinal cord injury (SCI). However, little is known about what strategies used by HEPs increase PA behavior in persons with SCI, or what factors influence HEPs when promoting PA to persons with SCI. The purposes of this scoping review were to (1) ascertain the extent, range and nature of the literature, (2) identify strategies used by HEPs that are associated with an increase in PA behavior for persons with SCI, and (3) identify the facilitators and barriers to PA promotion by the HEPs.Methods:A comprehensive search was undertaken. Search terms were expanded surrounding three key terms: PA, promotion, and SCI.Results:Twenty-four articles representing 18 unique studies were identified. HEPs predominantly consisted of physiotherapists, occupational therapists, and leisure trainers/therapists. Most interventions were delivered by HEPs to persons with SCI in in-patient rehabilitation centres and community-based settings. Tailored exercise programs and on-going counseling support were considered essential for increasing PA behavior. HEPs’ common barriers to PA promotion were perceived lack of time, education, and training.Conclusion:A need to improve and sustain SCI-specific PA knowledge and education was identified if PA promotion is to become a structured and integral component of practice. This study provides valuable information for interventions to increase PA behavior among persons with SCI by improving PA promotion by HEPs.     

Risk factors for osteoporotic fractures in persons with spinal cord injuries and disorders

Summary

Clinical risk factors for fracture were explored among Veterans with a spinal cord injury. At the end of 11 years of follow-up, the absolute risk of fracture was approximately 20 %. Among the clinical and SCI-related factors explored, a prior history of fracture was strongly associated with incident fracture.

Introduction

Few studies to date have comprehensively addressed clinical risk factors for fracture in persons with spinal cord injury (SCI). The purpose of this study was to identify risk factors for incident osteoporotic fractures in persons with a SCI that can be easily determined at the point of care.

Methods

The Veteran’s Affairs Spinal Cord Dysfunction Registry, a national database of persons with a SCI, was used to examine clinical and SCI-related risk factors for fracture. Incident fractures were identified in a cohort of persons with chronic SCI, defined as SCI present for at least 2 years. Cox regression models were used to estimate the risk of incident fractures.

Results

There were 22,516 persons with chronic SCI included in the cohort with 3365 incident fractures. The mean observational follow-up time for the overall sample was 6.2 years (median 6.0, IQR 2.9–11.0). The mean observational follow-up time for the fracture group was 3.9 years (median 3.3, IQR 1.4–6.1) and 6.7 years (median 6.7, IQR 3.1–11.0) for the nonfracture group. By the end of the study, which included predominantly older Veterans with a SCI observed for a relatively short period of time, the absolute (i.e., cumulative hazard) for incident fractures was 0.17 (95%CI 0.14–0.21). In multivariable analysis, factors associated with an increased risk of fracture included White race, traumatic etiology of SCI, paraplegia, complete extent of SCI, longer duration of SCI, use of anticonvulsants and opioids, prevalent fractures, and higher Charlson Comorbidity Indices. Women aged 50 and older were also at higher risk of sustaining an incident fracture at any time during the 11-year follow-up period.

Conclusions

There are multiple clinical and SCI-related risk factors which can be used to predict fracture in persons with a SCI. Clinicians should be particularly concerned about incident fracture risk in persons with a SCI who have had a previous fracture.

     

Rehabilitation Interventions to modify endocrine-metabolic disease risk in Individuals with chronic Spinal cord injury living in the Community (RIISC): A systematic review and scoping perspective

Context: Endocrine-metabolic disease (EMD) risk following spinal cord injury (SCI) is associated with significant multi-morbidity (i.e. fracture, diabetes, heart disease), mortality, and economic burden. It is unclear to what extent rehabilitation interventions can modify EMD risk and improve health status in community-dwelling adults with chronic SCI.

Objectives: To characterize rehabilitation interventions and summarize evidence on their efficacy/effectiveness to modify precursors to EMD risk in community-dwelling adults with chronic SCI.

Methods: Systematic searches of MEDLINE PubMed, EMBASE Ovid, CINAHL, CDSR, and PsychInfo were completed. All randomized, quasi-experimental, and prospective controlled trials comparing rehabilitation/therapeutic interventions with control/placebo interventions in adults with chronic SCI were eligible. Two authors independently selected studies and abstracted data. Mean differences of change from baseline were reported for EMD risk outcomes. The GRADE approach was used to rate the quality of evidence.

Results: Of 489 articles identified, 16 articles (11 studies; n=396) were eligible for inclusion. No studies assessed the effects of rehabilitation interventions on incident fragility fractures, heart disease, and/or diabetes. Individual studies reported that exercise and/or nutrition interventions could improve anthropometric indices, body composition/adiposity, and biomarkers. However, there were also reports of non-statistically significant between-group differences.

Conclusions: There was very low-quality evidence that rehabilitation interventions can improve precursors to EMD risk in community-dwelling adults with chronic SCI. The small number of studies, imprecise estimates, and inconsistency across studies limited our ability to make conclusions. A high-quality longitudinal intervention trial is needed to inform community-based rehabilitation strategies for EMD risk after chronic SCI.     

Living with spinal cord injury in Mongolia: A qualitative study on perceived environmental barriers

Context: Environmental factors play a key role in the lives of individuals with a spinal cord injury (SCI). This study identifies environmental barriers and their impacts on daily lives as perceived by individuals living with SCI in Mongolia.

Design: A qualitative study with semi-structured interviews was conducted. A topic guide for the interviews was structured around the components of the International Classification of Functioning, Disability, and Health.

Setting: Urban and rural areas of Mongolia.

Participants: A purposive sample of 16 persons with traumatic SCI.

Interventions: Not applicable.

Outcome Measures: Not applicable.

Results: Seven categories of environmental barriers were mentioned, such as poor access to the physical environment, absence of wheelchair-friendly transportation, negative societal attitudes, inadequate health and rehabilitation services, lack of access to assistive devices and medicines, limited financial resources for healthcare, and inaccurate categorization of disabilities in laws. These barriers were claimed to have an impact on physical and psychological health, limit activities, and restrict participation in almost all areas of life.

Conclusion: This study contributes to the identification of targets for interventions aimed at improving the lived experience of persons with SCI in a low-resource context. The findings reveal that while the Mongolian government already has laws and policies in place to improve access to the physical environment, transportation, assistive devices and employment, much more has to be done in terms of enforcement. Specialized SCI care and rehabilitation services are highly demanded in Mongolia.     

Dynamics of interpedicular widening in spinal burst fractures: an in vitro investigation

Background contextSpinal burst fractures are a significant cause of spinal instability and neurologic impairment. Although evidence suggests that the neurologic trauma arises during the dynamic phase of fracture, the biomechanics underpinning the phenomenon has yet to be fully explained. Interpedicular widening (IPW) is a distinctive feature of the fracture but, despite the association with the occurrence of neurologic deficit, little is known about its biomechanics.PurposeTo provide a comprehensive in vitro study on spinal burst fracture, with special attention on the dynamics of IPW.Study designExperimental measurements in combination with computed tomography scanning were used to quantitatively investigate the biomechanics of burst fracture in a cadaveric model.MethodsTwelve human three-adjacent-vertebra segments were tested to induce burst fracture. Impact was delivered through a drop-weight tower, whereas IPW was continuously recorded by two displacement transducers. Computed tomography scanning aided quantifying canal occlusion (CO) and evaluating sample anatomy and fracture appearance. Two levels of energy were delivered to two groups: high energy (HE) and low energy (LE).ResultsNo difference was found between HE and LE in terms of the residual IPW (ie, post-fracture), maximum IPW, or CO (median 20.2%). Whereas IPW was not found to be correlated with CO, a moderate correlation was found between the maximum and the residual IPW. At the fracture onset, IPW reached a maximum median value of 15.8% in approximately 20 to 25 milliseconds. After the transient phase, the pedicles were recoiled to a median residual IPW of 4.9%.ConclusionsOur study provides for the first time insight on how IPW actually evolves during the fracture onset. In addition, our results may help shedding more light on the mechanical initiation of the fracture.     

Characteristics and outcomes of hip fractures in lower limb amputees

IntroductionLower limb amputees, regardless of age are at an increased risk of developing fragility fractures of the neck of femur. The characteristics and outcomes of the fractures of the neck of femur in lower limb amputees have not been studied in detail.MethodsWe undertook a retrospective review of a prospectively collected single centre and single surgeon database between March 1996 and January 2017, using a standard proforma to identify patients who required surgical intervention for fracture neck of femur and had sustained a previous lower limb amputation and compared them with a cohort of standard hip fracture patients.ResultsTwenty-seven patients, sustaining 28 fractures of the neck of femurs were identified of which 16 were females with mean age of 78 years (50-89). Nineteen fractures were sustained on the ipsilateral side of the amputation. Results showed that seventy percent of amputees returned to their previous level of mobility and prior residence. Mortality in this group is higher as compared to a standard hip fracture patient but pain and mobility were comparable in both groups.DiscussionThe incidence of both hip fractures and amputations in increasing worldwide but no study has compared outcomes of hip fractures in amputees and compared them to a standard hip fracture patient. Amputees exhibit reduced bone density both at the hip and stump end which increases risk for osteoporosis and fragility fractures in the hip. The management of our patients followed orthopaedic principles, well established surgical interventions and rehabilitation.ConclusionThis study reveals that hip fractures in amputees can have comparable results to a standard hip fracture cohort if preoperative optimisation, planning and postoperative rehabilitation is carried out.     

The state of aquatic therapy use for clients with spinal cord injury or disorder: Knowledge and current practice

Context/objectivesAquatic therapy (AT) has been reported to be beneficial for individuals with spinal cord injury or disorder (SCI/D); however, AT has also been reported to be underutilized in SCI/D rehabilitation. We aimed to understand the knowledge and current practice of AT for clients with SCI/D by physiotherapists, physiotherapy assistants and kinesiologists across Canada.Design/MethodA survey with closed- and open-ended questions was distributed (July-October 2019) to professionals through letters sent by professional associations. Non-parametric analyses were used to compare AT knowledge and practice between AT and non-AT users; content analysis was used to identify the themes from open-ended questions.ResultsSeventy-eight respondents from 10 provinces were included in the analysis: 33 physiotherapists, 5 physiotherapy assistants and 40 kinesiologists. Respondents using AT (73%) reported greater knowledge of AT benefits and confidence to apply AT than respondents not using AT (p<0.01). Four themes were identified: 1-Variety of physical and psychosocial benefits of AT for people with SCI/D; 2-Attainment of movement and independence not possible on land; 3-Issues around pool accessibility; and 4-Constraints on AT implementation.ConclusionsRespondents implemented AT to improve health outcomes for patients with SCI/D, despite facing challenges with pool accessibility and numerous constraints. Respondents who provided AT reported having better knowledge of AT and a supported AT practice in the work environment than respondents not providing AT. This study will inform AT stakeholders and institutions when considering strategies to increase the access to AT after SCI/D.     

Nitrite and Leukocyte Dipstick Testing For Urinary Tract Infection in Individuals With Spinal Cord Injury

Abstract

Objective: Todetermine sensitivity, specificity, and positive and negative predictive values of nitrite (NIT) and leukocyte esterase (LE) testing in relation to Iabaratory evidence of significant bacteriuria and urinary tract infection (UTI) in persons with spinal cord injury (SCI).

Design: Monthly urine cultures were compared with results of dipstick testing. Setting: Community based.

Methods: Fifty-six people with SCI were evaluated on a monthly basis with dipstick testing for NIT and LE as weil as urine cultures. Participants reported whether they believed that they had a UTI and, if so, whether they were treated for the UTI and what symptoms they had experienced.

Results: The sensitivity rate for the most comprehensive criteria-defined as positive NIT test, a positive LE positive, or both a positive NIT test and positive LE test-was 0.64 and the specificity rate was only 0.52. No singletype ofbacteria was found to occur in more than 3 0% of the urine samples.

Conclusion: Reliance on dipstick testing for NIT and LEin individuals with SCI can Iead to high rates of overtreatment for UTI, given the fact that regular catheterization is associated with significant bacteriuria. lndividuals with SCI should be evaluated with urine culture to ensure proper treatment.     

The SCIRehab project: treatment time spent in SCI rehabilitation. Physical therapy treatment time during inpatient spinal cord injury rehabilitation

Background/objective

To describe the nature and distribution of activities during physical therapy (PT) delivered in inpatient spinal cord injury (SCI) rehabilitation and discuss predictors (patient and injury characteristics) of the amount of time spent in PT for specific treatment activities.

Methods

Six hundred patients from six inpatient SCI centers were enrolled in the SCIRehab study. Physical therapists documented details, including time spent, of treatment provided during 37 306 PT sessions that occurred during inpatient SCI rehabilitation. Ordinary least squares regression models associated patient and injury characteristics with time spent in specific PT activities.

Results

SCIRehab patients received a mean total of 55.3 hours of PT over the course of their rehabilitation stay. Significant differences among four neurologic groups were seen in the amount of time spent on most activities, including the most common PT activities of strengthening exercises, stretching, transfer training, wheelchair mobility training, and gait training. Most PT work (77%) was provided in individual therapy sessions; the remaining 23% was done in group settings. Patient and injury characteristics explained only some of the variations seen in time spent on wheelchair mobility, transfer and bed mobility training, and range of motion/stretching.

Conclusion

Analysis yielded both expected and unexpected trends in SCI rehabilitation. Significant variation was seen in time spent on PT activities within and among injury groups. Providing therapeutic strengthening treatments consumed the greatest proportion of PT time. About one-quarter of all PT services were provided in group settings. Details about services provided, including time spent, will serve as a starting point in detailing the optimal treatment delivery for maximal outcomes.     

The effects of spinal cord injury on bone healing in patients with femoral fractures

Abstract

Background

Orthopedic literature states that fractures of long bones, when associated with traumatic brain injuries, frequently heal with excessive callus and faster than normal. Few studies, however, have reported these phenomena being induced by spinal cord injury (SCI). Our objective is to compare the extent of callus and the rate of healing of long-bone fractures in patients with or without SCI. Subgroup comparisons were performed among the patients with SCI in terms of different levels of SCI.

Methods

The final mean volume of callus formation and the rate of union of nailed fractures of the femur were determined radiologically in 22 femoral fracture patients with SCI (seven cervical, six thoracic, and nine lumbar spine injury) and compared with those in a group of 22 patients with similar types of fractures but without SCI.

Results

The final mean callus volume in the fracture/SCI group was significantly higher than the fracture-only group (P < 0.001). The fractures in the fracture/SCI group united in an average time of 22.86 weeks compared with 25.04 weeks in the fracture-only group (P < 0.05). We observed 84.6% (11 of 13) of patients with cervical and thoracic SCI patients with accelerated fracture healing (cervical 6 of 7, thoracic 5 of 6), but only 44.4% (4 of 9) of patients with lumbar SCI appeared to show this phenomenon (P < 0.05).

Conclusions

These results confirm that SCI may be associated with accelerated fracture healing and enhanced callus formation. Furthermore, our study revealed a trend toward enhanced osteogenesis in cervical or thoracic SCI compared with lumbar SCI.     

Lower extremity fractures in patients with spinal cord injury characteristics,outcome and risk factors for non-unions

Context: Sublesional osteoporosis is an important sequel after spinal cord injury (SCI) resulting in a high incidence of fractures and impaired osseous healing due to altered bone metabolism. The following study aims to identify demographic characteristics and outcome of patients with SCI with lower extremity fractures.

Design: Retrospective observational study.

Setting: Level-I cross-regional trauma center.

Participants: All patients with SCI suffering from osteoporotic/pathologic fractures during an 11-year-period (01/2003–12/2013) at the Center for Spinal Cord Injuries (Trauma Center Murnau) were analyzed via a chart review.

Outcome measures: Demographics, surgical and radiologic outcome as well as complication rate were assessed with a special emphasis on union rates and independent risk factors for non-unions.

Results: We identified 132 patients (105 males) who fulfilled the inclusion criteria. Most of them were paraplegic (n=101) and showed motor complete syndromes (n=119). Supracondylar femur fractures were the most prevalent in this study (n=47). We observed a non-union rate of 15.9% (n=21). The development of pseudarthrosis was associated with the time interval since the initial SCI (P < 0.010), delayed in-patient submission (P < 0.038), fracture classification (P < 0.002) and the localization of the fracture (P < 0.0001). The overall complication rate was 16.7%. All dislocated subtrochanteric femur fractures (Garden III and IV) (n=10) developed a non-union, regardless of their management (conservative or surgical). The following independent predictors for non-unions were identified: fracture localization (P < 0.0002), fracture classification (P < 0.056), and fracture management (P < 0.036).

Conclusions: Even though modern techniques allow surgical interventions in bones with reduced mineral density, non-unions remain a common complication in patients with SCI. Risk factors for non-unions of lower extremity fractures are identified.