Case Diagnosis: 51 year old with thoracic myelopathy and lower extremity spasticity with recent baclofen pump placement with nontraumatic femoral fracture
Case Description: Patient was admitted to inpatient rehabilitation after revision of thoracolumbar hardware. He had a history of non-traumatic thoracic incomplete spinal cord injury and underwent T5-T10 laminectomies for decompression 11 months earlier and was non-ambulatory. His postoperative course was complicated by decreased independence secondary to significant lower extremity spasticity. He recently had an intrathecal baclofen pump placed 4 months prior that would benefit from titration and was therefore admitted to acute rehabilitation. During his stay he was independently stretching using thigh straps when he suddenly heard a “pop” in his left knee followed by immediate swelling. He did not experience any pain but notably does not have any pin prick sensation in his lower extremities. On physical examination he had complete laxity of the knee. There was initially concern for ligamentous injury; however, radiograph revealed left distal femoral diaphyseal fracture. Orthopedic surgery was consulted and the patient underwent uncomplicated internal fixation of femur fracture.
Discussion: Patients with spinal cord injuries are at increased risk of osteoporosis and fragility fractures. There are new guidelines on bone health in spinal cord injury but they do not discuss precautions for future admissions to acute rehabilitation or specific precautions for therapy.
Setting: University Inpatient Rehabilitation Hospital
Assessment/Results: Chart review of Vitamin D demonstrated 29ng/mL during his initial hospitalization in 2022, his admission level was 14 ng/mL in 2023. Patient was not on a daily supplementation. No DEXA had been completed since injury. No comment of concern for osteoporosis in prior x-rays.
Conclusion: Fragility fractures in patients with spinal cord injury should raise discussion if screening of low bone density should be performed prior to acute rehabilitation in sub-acute/chronic patients.
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