(Kiosk 5) Intertrochanteric Fracture in Chronic Spinal Cord Injury Patient While in Inpatient Rehabilitation: examining the Role of Pre-rehabilitation Assessment

Case Diagnosis: Low intensity intertrochanteric fracture in patient with chronic spinal cord injury (SCI)

Case Description: A 54 year old female one year status post spinal cord injury (SCI) from gunshot wound presented to inpatient rehabilitation (IPR) with a stage IV pressure ulcer for SCI education. She was admitted due to the lack of SCI education, good potential for independence, and a wound that could be offloaded when seated. Abdominal x-rays were performed with indication of osteoporosis of the hip but no bone lesions or fractures were noted. Increased swelling to bilateral lower extremities, left worse than right, was observed one week into her rehabilitation. Bilateral doppler was negative for DVT. Due to ongoing edema and abdominal pain, a CTA abdomen pelvis was performed. A large hematoma surrounding a comminuted intertrochanteric fracture of the left femur was found. She reported that nearly a week prior to the scan she had heard an audible pop while performing a maneuver.

Discussion: Given low intensity of fracture, pathologic fracture secondary to tumor was considered. US guided biopsy of the lesion was performed and the patient underwent surgical fixation of the left femur. She resumed her therapy and was eventually discharged home with improved independence measures from when she first arrived.

Setting: Inpatient Rehabilitation Hospital

Assessment/Results: Assessment of bone density has been suggested as a method of evaluation of rehabilitation appropriateness with SCI patients. Osteoporosis is common in SCI and leads to increased risk of fractures while participating in therapy. Although a fracture is undesirable, the risk should be balanced with improvement in quality of life gained at IPR.

Conclusion: Physiatrists should be aware of the potential for major fractures in chronic SCI patients once they begin IPR as this could lead to serious complications during their stay. A framework for accepting patients with sub-lesional osteoporosis to IPR should be established.