Surgical and Conservative Treatment of lower Limb Fractures in Patients with Chronic Spinal Cord Injury

Surgical and Conservative Treatment of lower Limb Fractures in Patients with Chronic Spinal Cord Injury | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Surgical and Conservative Treatment of lower Limb Fractures in Patients with Chronic Spinal Cord Injury Frederik Schneckmann, Alexander Klug, Tim Jakobi, Annika Werner, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6185684/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 07 Nov, 2025 Read the published version in Spinal Cord → Version 1 posted 10 You are reading this latest preprint version Abstract Study Design: A 10-year single-center retrospective chart review Objective: To evaluate the differences between conservative and surgical treatment of long bone fractures in individuals with chronic SCI, focusing on wheelchair mobilization, overall hospital days, and complication rates. Setting: Spinal cord injury Department, BG Trauma Center Frankfurt am Main, Germany Methods: The study, conducted between 2014 and 2023, compared conservative and surgical treatment for long bone fractures in individuals with chronic SCI using descriptive statistics. Results: A total of 58 long bone fractures were included, with 31 surgically and 27 conservatively treated. Patient characteristics (age, gender, SCI level, fracture complexity) did not differ between groups (p > 0.05). The median time to first wheelchair mobilization was 14 days for both groups (p = 0.38), and there was no significant difference in hospital stay (p = 0.98). Only one surgically treated case (3.2%) had delayed wound healing, while 9 out of 31 non-surgically treated cases had complications, leading to a significantly higher complication rate for non-surgical treatment (p = 0.002). Conclusion: Non-surgical treatment had a higher complication rate than surgical treatment. Both approaches were equivalent in time to first wheelchair mobilization, and neither showed a significantly shorter hospital stay. Sponsorship: non Health sciences/Health care/Fracture repair Health sciences/Medical research/Outcomes research Health sciences/Medical research/Epidemiology Figures Figure 1 Figure 2 Figure 3 Introduction Individuals with chronic spinal cord injury (SCI) are at a high risk for fractures, particularly in the long bones of the lower extremities [ 1 ], with an estimated annual incidence ranging from 2% to 7,4% [ 2 ] [ 3 ]. This vulnerability is especially pronounced in the trabecular regions, where bone loss progresses rapidly in the early stages of SCI, notably affecting the distal femur and proximal tibia [ 4 ]. Studies indicate that between one-third and one-half of individuals with SCI will experience at least one sublesional fracture as a secondary complication [ 5 ] [ 6 ]. Managing fractures in patients with chronic SCI presents unique clinical challenges, such as reduced bone density due to disuse osteoporosis and impaired sensation and sensitivity, which can delay diagnosis and treatment [ 7 ]. Historically, treatment has predominantly relied on conservative approaches, such as limb immobilization, rather than surgical fixation [ 8 ]. However, conservative management carries notable risks, including soft tissue damage due to impaired epicritic sensitivity and potential trophic disturbances from casts, orthoses, or other immobilization devices [ 7 ]. Conversely, surgical osteosynthesis is associated with concerns such as delayed wound healing and the risk of implant loosening, particularly in the context of sublesional osteoporosis and compromised skin integrity in paralyzed regions. These challenges necessitate a tailored, case-by-case approach to determine the most appropriate treatment strategy [ 9 ]. Generally, there is a limited scientific research and scant evidence regarding the preferred approach — surgical versus conservative — for managing extremity fractures in the lower limbs of individuals with spinal cord injury. While current studies often advocate for surgical intervention due to its lower complication rates compared to conservative treatments [ 7 ], no investigations have examined the relative impact of these approaches on critical outcomes such as time to wheelchair mobilization or hospital stay duration. Methods Study design and Setting This study was conducted at the Center for Spinal Cord Injuries, a specialized facility exclusively dedicated to the treatment of patients with spinal cord injuries (SCI). The center operates as an over-regional trauma center within a metropolitan area in central Germany. A retrospective analysis was performed on all patients admitted to our institution over a 10-year period (2012–2023). To be included in the study, patients had to be over the age of 18, have a chronic SCI, and have sustained a fracture. All fractures outside the lower extremity, including those of the spine, skull, and hand, were excluded from the analysis. Additionally, all fractures were classified according to the AO classification system. The study sample was divided into two groups based on whether the fracture was managed conservatively or treated surgically. To compare the two groups, the following data were collected: the number of days until patients were able to transfer into a wheelchair for the first time after the fracture, as this mobility is essential for their independence; the duration of hospital stay; and any documented complications during ongoing treatment, including those related to prolonged immobilization, such as pressure sores or delayed rehabilitation. Statistical analysis All statistics analyses were done using the software SPSS 29.0.2.0. SCI-Patients with fractures were divided in two groups: conservative treatment and operative treatment. Each variable was tested for normal distribution (by Kolmogorov-Smirnov and Shapiro-Wilk tests) before differences between the two groups were assessed. For continuous variables that were normally distributed, t-tests were used, and for other continuous variables, Mann-Whitney U tests were applied. Categorical variables (e.g. sex, AIS grade, and SCI level) were compared using the χ 2 test to assess the difference between the two groups the reference group at a statistical significance level of 0.05 with a confidence interval of 95% was used. Results In total, 65 fractures were identified during the study period. However, 7 fractures were excluded (3 humerus fractures, 2 pelvic fractures, and 2 tarsal bone fractures), as the study focused exclusively on the lower extremity. The remaining 58 fractures were all located in the major long bones of the lower extremity an were treated either surgically (n=31) or conservatively (n=27). Overall, there was a higher prevalence of male patients in both the surgically treated group (n=17; 63%) and the conservatively treated group (n=23; 74%). Table 1 General characteristics of the studied population at the time of the first fracture event and according to the type of fracture management Overall Surgical Non - surgical Patients included 58 (100%) 31 (53,4%) 27 (46,6%) Sex Male 40 (69,0%) 23 (74,2%) 17 (63,0%) Female 18 (31,0%) 8 (25,8%) 10 (37,0%) SCI level Cervical 15 (25,9%) 9 (29,0%) 6 (22,2%) Thoracic 33 (56,9%) 19 (61,3%) 14 (51,9%) Lumbar 10 (17,2%) 3 (9,7%) 7 (25,9%) AIS A 36 (62,1%) 13 (41,9%) 23 (85,2%) B 6 (10,3%) 5 (16,1%) 1 (3,7%) C 13 (22,4%) 11 (35,5%) 2 (7,4 %) D 3 (5,2%) 2 (6,2 %) 1 (3,7%) Age (years) Median 25% percent. 75% percent. 57 54 60 58 54 64 55 48 63 Time of SCI Median 25% percent. 75% percent. 22 13 31 22 1 4 30 24 11 39 However, there was no significant gender differences between the two groups (p=.36). Similarly, no significant difference was observed in age (p=.23) between the surgically and conservatively treated patients. The mean age at the time of the fracture was comparable between both groups. There was no significant difference between the two groups in terms of the level of SCI (P=.27) or the time lag between the SCI and the fracture (p=.75), as the median time was 22 years for surgically treated patients and 24 years for those treated conservatively. A significant difference (p=.01) was observed between the groups, with 85% (n=23) of conservatively treated patients being completely paraplegic, while more than half (n=17; 58%) of surgically treated patients had incomplete paraplegia. 48 fractures were attributed to falls from wheelchairs or incidents occurring during transfers between a wheelchair and a bed or vehicle, whereas the remainder were associated with falls in the bathroom, such as from the toilet or during personal hygiene activities. In three cases, no discernible trauma could be identified in the patient history. Notably, the knee region was particularly impacted, representing almost 30% of all fractures. 10 fractures (17.2% of all included fractures) were located in the distal femur, while 9 were in the proximal tibia. Of the 19 fractures in this region, all intra-articular knee fractures (n=9; 14%) were managed conservatively. In contrast, fractures of the proximal femur or femoral shaft were predominantly treated surgically. Tibial shaft fractures (n=9; 14%) were managed with both conservative (n=4; 44%) and surgical (n=5; 56%) treatments, with no clear preference for either approach. Table 2 Fracture classification and localisation according to the AO Classification Overall Surgical Non - surgical Patients included 58 (100%) 31 (53,4%) 27 (46,6%) AO -Classification A 41 (100%) 24 (58,5%) 17 (41,5%) B 12 (100%) 5 (41,7%) 7 (58,3%) C 5 (100%) 2 (40,0%) 3 (60,0 %) Femur fracture AO 31 (prox.) 12 (100%) 10 (83,3%) 2 (16,7%) AO 32 (shaft) 9 (100%) 8 (88,9%) 1 (11,1%) AO 33 (distal) 10 (100%) 2 (20,0%) 8 (80,0%) Tibia Fracture AO 41 (prox.) 9 (100%) 5 (55,6%) 4 (44,4%) AO 42 (shaft) 9 (100%) 5 (55,6%) 4 (44,4%) AO 43 (distal) 7 (100%) 1 (14,3%) 6 (85,7%) As a next step we analyzed our patients according to non-surgical and surgical complication rates. We observed an overall complication rate of 15% (n=10), where 90% of all complications were seen in the non-surgical treatment cohort. In the surgical treatment group, there was only one case of wound healing disturbance with prolonged wound drainage, but no revision surgery was required. The implant loosening described in the literature was not observed in any case. In the conservatively treated patients, pressure injuries under the cast or pressure ulcers were the most common complications observed. Five of the nine pressure ulcera observed in the conservatively treated group healed completely without complications before discharge through cushioning adjustments or reapplication of the cast. In one-third of the cases, extensive conservative wound therapy was required, lasting between 3 and 10 months, due to limited possibilities for pressure relief and poor blood circulation. In one case, plastic surgical coverage was necessary. Complications were particularly common in fractures with joint involvement. Overall, of the nine intra-articular fractures, approximately 45.0% (n=4) showed complications, primarily in the form of soft tissue damage. All complications in the conservative treatment group occurred in individuals with complete paraplegia. Regarding mobility in the wheelchair, no significant differences (p.98) were observed between the surgical (median: 14; 25% percentil: 7; 75% percentil: 23) and conservative treatment (median: 14; 25% percentil: 4; 75% percentil: 17). Similarly, regarding the length of hospital stay due to the fracture, neither the surgical (median: 24; 25% percentil: 17; 75% percentil: 44) nor the non-surgical treatment regimen (median: 32; 25% percentil: 13; 75% percentil: 48) demonstrated an advantage over the other (p=0.98). Discussion At least one sublesional fracture as a secondary condition will occur in between one-third and one-half of individuals with SCI [ 5 ] [ 6 ]. Typically, most fractures occur following an accident during a wheelchair transfer, such as into bed, or a fall from the wheelchair [ 10 ], as demonstrated in this study. Consistent with existing literature [ 11 ], in this study the majority of fractures were found to occur around the knee joint. The optimal treatment of fractures of the long bones presents a significant challenge, particularly when it comes to selecting the appropriate therapeutic regimen, whether conservative or surgical. However, to date, there is no consensus on the optimal treatment of lower extremity fracture complications in patients with an SCI [ 12 ]. Key aspects in the decision-making process include timely mobilization into a wheelchair, length of hospital stay, and the management and occurrence of complications. To our knowledge, this study represents the largest overview on this topic in recent years. Several studies have suggested that surgical treatment of fractures in SCI patients may expedite post-fracture mobilization [ 13 ] [ 14 ]. The results of the fractures included in this study did not confirm this assumption, as the patients took on average 3 days longer to achieve their first mobilization. This could be attributed to the fact that most patients initially sought medical attention several days after the trauma and were then transferred to our hospital, missing the optimal window for immediate fracture treatment. Additionally, due to the pronounced swelling of the skin and soft tissue, surgery had to be delayed, which may have contributed to the time difference. In some studies in the literature, such as [ 15 ], based on a similarly sized patient population, the average hospital stay was reported to be ten days longer. This extended duration may be due in part to the practice of discharging patients only after radiologically confirmed signs of healing, along with the fact that the data are over 30 years old. The majority of the conservatively treated intra-articular fractures in this study, particularly those of the proximal tibia and distal femur, exhibited a significantly higher incidence of complications, primarily soft tissue damage to the affected extremity, compared to surgically treated fractures. The underlying mechanisms for this association remain unclear in the existing literature. However, the authors of this study hypothesize that intra-articular involvement may contribute to an increase in spasticity, which could, in turn, elevate the risk of pressure-induced soft tissue damage in the presence of an immobilizing cast. Among the fractures treated conservatively, nearly 15% occurred in patients with incomplete spinal cord injuries. Given this distribution, it is unsurprising that 8 out of the 9 complications in the conservative treatment group, primarily soft tissue complications, were observed in patients with complete spinal injuries. This observation further suggests that, due to the loss of epicritic sensation in the lower extremities, patients classified as ASIA may be particularly vulnerable to complications from non-surgical treatment. Limitations One limitation of this study, inherent in its retrospective design, is the absence of radiological follow-up for all patients. As a result, we were unable to assess the extent to which bony consolidation had occurred in the patients included. This factor might have affected the outcome measures, particularly regarding the healing process and the evaluation of the fracture's progression. Conclusion In summary, a significantly higher incidence of complications is observed with conservative therapy. Although surgical treatment does not enable individuals with spinal cord injuries to achieve significantly faster mobilization into a wheelchair or a significantly shorter hospital stay, the high incidence of soft tissue complications due to immobilization underscores the necessity of regular and resource-intensive soft tissue monitoring. In particular, fractures with intra-articular involvement appear to be especially at risk for complications. Furthermore, complications were significantly more frequent in patients with complete spinal cord injuries compared to those with incomplete injuries. Given the substantial time and nursing resources required for conservative management, and the fact that no cases of symptomatic implant loosening were observed, the authors recommend surgical treatment for fractures of the long bones in the lower extremities to optimize both clinical outcomes and resource allocation. Declarations Data Available Statement The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request. Ethical Approval The study has received approval from the Ethics Committee of the State Medical Association of Hesse, with the reference number 2024-3798-evBO. References Gifre L, Vidal J, Carrasco J, Portell E, Puig J, Monegal A, u. a. Incidence of skeletal fractures after traumatic spinal cord injury: a 10-year follow-up study. Clin Rehabil. April 2014;28(4):361–9. Zehnder Y, Lüthi M, Michel D, Knecht H, Perrelet R, Neto I, u. a. Long-term changes in bone metabolism, bone mineral density, quantitative ultrasound parameters, and fracture incidence after spinal cord injury: a cross-sectional observational study in 100 paraplegic men. Osteoporos Int. März 2004;15(3):180–9. Pelletier CA, Dumont FS, Leblond J, Noreau L, Giangregorio L, Craven BC. Self-report of one-year fracture incidence and osteoporosis prevalence in a community cohort of canadians with spinal cord injury. Top Spinal Cord Inj Rehabil. 2014;20(4):302–9. Garland DE, Adkins RH, Kushwaha V, Stewart C. Risk factors for osteoporosis at the knee in the spinal cord injury population. J Spinal Cord Med. 2004;27(3):202–6. Battaglino RA, Lazzari AA, Garshick E, Morse LR. Spinal cord injury-induced osteoporosis: pathogenesis and emerging therapies. Curr Osteoporos Rep. Dezember 2012;10(4):278–85. Lazo MG, Shirazi P, Sam M, Giobbie-Hurder A, Blacconiere MJ, Muppidi M. Osteoporosis and risk of fracture in men with spinal cord injury. Spinal Cord. April 2001;39(4):208–14. Fouasson-Chailloux A, Gross R, Dauty M, Gadbled G, Touchais S, Le Fort M, u. a. Surgical management of lower limb fractures in patients with spinal cord injury less associated with complications than non-operative management: A retrospective series of cases. J Spinal Cord Med. Januar 2019;42(1):39–44. Ragnarsson KT, Sell GH. Lower extremity fractures after spinal cord injury: a retrospective study. Arch Phys Med Rehabil. September 1981;62(9):418–23. Grassner L, Klein B, Maier D, Bühren V, Vogel M. Lower extremity fractures in patients with spinal cord injury characteristics, outcome and risk factors for non-unions. J Spinal Cord Med. November 2018;41(6):676–83. Akhigbe T, Chin AS, Svircev JN, Hoenig H, Burns SP, Weaver FM, u. a. A retrospective review of lower extremity fracture care in patients with spinal cord injury. J Spinal Cord Med. Januar 2015;38(1):2–9. Bethel M, Bailey L, Weaver F, Le B, Burns SP, Svircev JN, u. a. Surgical compared with nonsurgical management of fractures in male veterans with chronic spinal cord injury. Spinal Cord. Mai 2015;53(5):402–7. Carbone LD, Ahn J, Adler RA, Cervinka T, Craven C, Geerts W, u. a. Acute Lower Extremity Fracture Management in Chronic Spinal Cord Injury: 2022 Delphi Consensus Recommendations. JB JS Open Access. 2022;7(4):e21.00152. Sugi MT, Davidovitch R, Montero N, Nobel T, Egol KA. Treatment of lower-extremity long-bone fractures in active, nonambulatory, wheelchair-bound patients. Orthopedics. September 2012;35(9):e1376-1382. Bishop JA, Suarez P, DiPonio L, Ota D, Curtin CM. Surgical versus nonsurgical treatment of femur fractures in people with spinal cord injury: an administrative analysis of risks. Arch Phys Med Rehabil. Dezember 2013;94(12):2357–64. Cochran TP, Bayley JC, Smith M. Lower extremity fractures in paraplegics: pattern, treatment, and functional results. J Spinal Disord. 1988;1(3):219–23. Additional Declarations There is a duality of interest Cite Share Download PDF Status: Published Journal Publication published 07 Nov, 2025 Read the published version in Spinal Cord → Version 1 posted Editorial decision: revise 17 Jun, 2025 Review # 2 received at journal 10 May, 2025 Reviewer # 2 agreed at journal 27 Apr, 2025 Review # 1 received at journal 19 Apr, 2025 Reviewer # 1 agreed at journal 12 Apr, 2025 Reviewers invited by journal 21 Mar, 2025 Submission checks completed at journal 17 Mar, 2025 First submitted to journal 16 Mar, 2025 Unknown event 11 Mar, 2025 Editor assigned by journal 08 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6185684","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":431942671,"identity":"13e7b912-dc6b-48ad-8365-0d9949779102","order_by":0,"name":"Frederik Schneckmann","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA00lEQVRIiWNgGAWjYBAC9gYGBgkGhgNAJhvjAzDjAAEtPAcQWpgNSNbCJkGcFunDB2/+qLmTx89+LK2ap+IOA9/xBgJa+NKSrXmOPSuW7Ek7dpvnzDMGyTMErLHn4TGTZmw4nLjhBnvb7dy2wwwGNxII2MLD/03yJ1DLfqCW4tx/QC33HxDSwsMmwQuyRYLtGHNuA8gW/DqAWtiMgX45nDjjTFqy9J9jz3gkzxB0GPNDYIgdTuxvP2b4cUbNHTm+4wcIWINhBonqR8EoGAWjYBRgAwCF90p5/rVlZgAAAABJRU5ErkJggg==","orcid":"","institution":"BG Unfallklinik Frankfurt am Main","correspondingAuthor":true,"prefix":"","firstName":"Frederik","middleName":"","lastName":"Schneckmann","suffix":""},{"id":431942672,"identity":"ad07134b-3f3b-4f1d-bec0-8437c50ada85","order_by":1,"name":"Alexander Klug","email":"","orcid":"","institution":"BG Unfallklinik Frankfurt am 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Modality\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6185684/v1/fb86f2b21ada61d88b4c1f07.jpg"},{"id":79585832,"identity":"7ec57599-d7f4-4922-a99f-713c39f025fd","added_by":"auto","created_at":"2025-03-31 12:29:03","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":33879,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eBoxplot for the First Mobility in wheelchair\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6185684/v1/b5eb3a63d2fc12511ca02f0a.jpg"},{"id":79585833,"identity":"e3554dd2-4b26-45ba-9e55-788fd5fd37c8","added_by":"auto","created_at":"2025-03-31 12:29:03","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":22243,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eBoxplot Lenght of stay in hospital\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6185684/v1/59857c491078fb4068faf29a.jpg"},{"id":95430492,"identity":"35b1c867-73f1-430a-80f8-1d9d80b35998","added_by":"auto","created_at":"2025-11-08 08:08:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":786503,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6185684/v1/26e11884-bb6c-4d83-bca4-5547f2770dde.pdf"}],"financialInterests":"There is a duality of interest","formattedTitle":"Surgical and Conservative Treatment of lower Limb Fractures in Patients with Chronic Spinal Cord Injury","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIndividuals with chronic spinal cord injury (SCI) are at a high risk for fractures, particularly in the long bones of the lower extremities [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], with an estimated annual incidence ranging from 2% to 7,4% [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis vulnerability is especially pronounced in the trabecular regions, where bone loss progresses rapidly in the early stages of SCI, notably affecting the distal femur and proximal tibia [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Studies indicate that between one-third and one-half of individuals with SCI will experience at least one sublesional fracture as a secondary complication [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eManaging fractures in patients with chronic SCI presents unique clinical challenges, such as reduced bone density due to disuse osteoporosis and impaired sensation and sensitivity, which can delay diagnosis and treatment [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHistorically, treatment has predominantly relied on conservative approaches, such as limb immobilization, rather than surgical fixation [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. However, conservative management carries notable risks, including soft tissue damage due to impaired epicritic sensitivity and potential trophic disturbances from casts, orthoses, or other immobilization devices [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eConversely, surgical osteosynthesis is associated with concerns such as delayed wound healing and the risk of implant loosening, particularly in the context of sublesional osteoporosis and compromised skin integrity in paralyzed regions.\u003c/p\u003e \u003cp\u003eThese challenges necessitate a tailored, case-by-case approach to determine the most appropriate treatment strategy [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Generally, there is a limited scientific research and scant evidence regarding the preferred approach — surgical versus conservative — for managing extremity fractures in the lower limbs of individuals with spinal cord injury. While current studies often advocate for surgical intervention due to its lower complication rates compared to conservative treatments [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], no investigations have examined the relative impact of these approaches on critical outcomes such as time to wheelchair mobilization or hospital stay duration.\u003c/p\u003e "},{"header":"Methods","content":"\u003cp\u003e \u003cb\u003eStudy design and Setting\u003c/b\u003e\u003c/p\u003e\u003cp\u003e This study was conducted at the Center for Spinal Cord Injuries, a specialized facility exclusively dedicated to the treatment of patients with spinal cord injuries (SCI). The center operates as an over-regional trauma center within a metropolitan area in central Germany. A retrospective analysis was performed on all patients admitted to our institution over a 10-year period (2012–2023). To be included in the study, patients had to be over the age of 18, have a chronic SCI, and have sustained a fracture. All fractures outside the lower extremity, including those of the spine, skull, and hand, were excluded from the analysis. Additionally, all fractures were classified according to the AO classification system. The study sample was divided into two groups based on whether the fracture was managed conservatively or treated surgically. To compare the two groups, the following data were collected: the number of days until patients were able to transfer into a wheelchair for the first time after the fracture, as this mobility is essential for their independence; the duration of hospital stay; and any documented complications during ongoing treatment, including those related to prolonged immobilization, such as pressure sores or delayed rehabilitation.\u003c/p\u003e\u003cp\u003e \u003cb\u003eStatistical analysis\u003c/b\u003e\u003c/p\u003e\u003cp\u003e All statistics analyses were done using the software SPSS 29.0.2.0. SCI-Patients with fractures were divided in two groups: conservative treatment and operative treatment. Each variable was tested for normal distribution (by Kolmogorov-Smirnov and Shapiro-Wilk tests) before differences between the two groups were assessed. For continuous variables that were normally distributed, t-tests were used, and for other continuous variables, Mann-Whitney U tests were applied. Categorical variables (e.g. sex, AIS grade, and SCI level) were compared using the χ 2 test to assess the difference between the two groups the reference group at a statistical significance level of 0.05 with a confidence interval of 95% was used.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eIn total, 65 fractures were identified during the study period. However, 7 fractures were excluded (3 humerus fractures, 2 pelvic fractures, and 2 tarsal bone fractures), as the study focused exclusively on the lower extremity. The \u0026nbsp;remaining 58 fractures were all located in the major long bones of the lower extremity an were treated either surgically (n=31) or conservatively (n=27). \u0026nbsp; \u0026nbsp; \u0026nbsp;Overall, there was a higher prevalence of male patients in both the surgically treated group (n=17; 63%) and the conservatively treated group (n=23; 74%). \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;General characteristics of the studied population at the time of the first fracture event and according to the type of fracture management\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"600\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27.3723%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurgical\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.4526%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNon - surgical\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27.3723%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatients \u0026nbsp; \u0026nbsp; included \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e58 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e31 (53,4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.4526%;\"\u003e\n \u003cp\u003e27 (46,6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27.3723%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.4526%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27.3723%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Male\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e40 (69,0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e23 (74,2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.4526%;\"\u003e\n \u003cp\u003e17 (63,0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27.3723%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e18 (31,0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e8 (25,8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.4526%;\"\u003e\n \u003cp\u003e10 (37,0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27.3723%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSCI level\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.4526%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27.3723%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Cervical\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e15 (25,9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e9 (29,0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.4526%;\"\u003e\n \u003cp\u003e6 (22,2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27.3723%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Thoracic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e33 (56,9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e19 (61,3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.4526%;\"\u003e\n \u003cp\u003e14 (51,9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27.3723%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Lumbar\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e10 (17,2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e3 (9,7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.4526%;\"\u003e\n \u003cp\u003e7 (25,9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27.3723%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAIS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.4526%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27.3723%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e36 (62,1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e13 (41,9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.4526%;\"\u003e\n \u003cp\u003e23 (85,2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27.3723%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;B\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e6 (10,3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e5 (16,1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.4526%;\"\u003e\n \u003cp\u003e1 (3,7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27.3723%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;C\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e13 (22,4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e11 (35,5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.4526%;\"\u003e\n \u003cp\u003e2 (7,4 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27.3723%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;D\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e3 (5,2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e2 (6,2 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.4526%;\"\u003e\n \u003cp\u003e1 (3,7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27.3723%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (years)\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMedian\u003c/p\u003e\n \u003cp\u003e25% percent.\u003c/p\u003e\n \u003cp\u003e75% percent. \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e57\u003c/p\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003cp\u003e64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.4526%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003cp\u003e63\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27.3723%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime of SCI\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMedian\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e25% percent.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e75% percent. \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003cp\u003e\u003cspan style='color: rgb(0, 0, 0); font-family: \"Times New Roman\"; font-size: medium; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; background-color: rgb(255, 255, 255); text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial; display: inline !important; float: none;'\u003e1\u003c/span\u003e4\u003c/p\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.4526%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;39\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eHowever, there was no significant gender differences between the two groups (p=.36). Similarly, no significant difference was observed in age (p=.23) between the surgically and conservatively treated patients. \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe mean age at the time of the fracture was comparable between both groups. There was no significant difference between the two groups in terms of the level of SCI (P=.27) or the time lag between the SCI and the fracture (p=.75), as the median time was 22 years for surgically treated patients and 24 years for those treated conservatively.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA significant difference (p=.01) was observed between the groups, with 85% (n=23) of conservatively treated patients being completely paraplegic, while more than half (n=17; 58%) of surgically treated patients had incomplete paraplegia.\u003c/p\u003e\n\u003cp\u003e48 fractures were attributed to falls from wheelchairs or incidents occurring during transfers between a wheelchair and a bed or vehicle, whereas the remainder were associated with falls in the bathroom, such as from the toilet or during personal hygiene activities. In three cases, no discernible trauma could be identified in the patient history.\u003c/p\u003e\n\u003cp\u003eNotably, the knee region was particularly impacted, representing almost 30% of all fractures. 10 fractures (17.2% of all included fractures) were located in the distal femur, while 9 were in the proximal tibia. Of the 19 fractures in this region, all intra-articular knee fractures (n=9; 14%) were managed conservatively.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn contrast, fractures of the proximal femur or femoral shaft were predominantly treated surgically.\u003c/p\u003e\n\u003cp\u003eTibial shaft fractures (n=9; 14%) were managed with both conservative (n=4; 44%) and surgical (n=5; 56%) treatments, with no clear preference for either approach.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Fracture classification and localisation according to the AO Classification\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"600\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27.7372%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurgical\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNon - surgical\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27.7372%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatients \u0026nbsp; \u0026nbsp; included \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e58 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e31 (53,4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e27 (46,6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27.7372%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAO -Classification\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27.7372%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e41 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e\u0026nbsp;24 (58,5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e17 (41,5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27.7372%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;B\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e12 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e5 (41,7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e7 (58,3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27.7372%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;C\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e\u0026nbsp;5 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e2 (40,0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e3 (60,0 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27.7372%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemur fracture \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27.7372%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;AO 31 (prox.)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e12 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e10 (83,3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e2 (16,7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27.7372%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;AO 32 (shaft)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e\u0026nbsp;9 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e8 (88,9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e1 (11,1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27.7372%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;AO 33 (distal)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e10 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e2 (20,0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e8 (80,0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27.7372%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTibia Fracture \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27.7372%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;AO 41 (prox.)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e9 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e5 (55,6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e4 (44,4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27.7372%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;AO 42 (shaft)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e9 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e5 (55,6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e4 (44,4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27.7372%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;AO 43 (distal)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e7 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e1 (14,3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.0876%;\"\u003e\n \u003cp\u003e6 (85,7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAs a next step we analyzed our patients according to non-surgical and surgical complication rates. We observed an overall complication rate of 15% (n=10), where 90% of all complications were seen in the non-surgical treatment cohort.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the surgical treatment group, there was only one case of wound healing disturbance with prolonged wound drainage, but no revision surgery was required. The implant loosening described in the literature was not observed in any case.\u003c/p\u003e\n\u003cp\u003eIn the conservatively treated patients, pressure injuries under the cast or pressure ulcers were the most common complications observed. Five of the nine pressure ulcera observed in the conservatively treated group healed completely without complications before discharge through cushioning adjustments or reapplication of the cast. In one-third of the cases, extensive conservative wound therapy was required, lasting between 3 and 10 months, due to limited possibilities for pressure relief and poor blood circulation. In one case, plastic surgical coverage was necessary.\u003c/p\u003e\n\u003cp\u003eComplications were particularly common in fractures with joint involvement. Overall, of the nine intra-articular fractures, approximately 45.0% (n=4) showed complications, primarily in the form of soft tissue damage.\u003c/p\u003e\u003cp\u003eAll complications in the conservative treatment group occurred in individuals with complete paraplegia.\u003c/p\u003e\n\u003cp\u003eRegarding mobility in the wheelchair, no significant differences (p.98) were observed between the surgical (median: 14; 25% percentil: 7; 75% percentil: 23) and conservative treatment (median: 14; 25% percentil: 4; 75% percentil: 17).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSimilarly, regarding the length of hospital stay due to the fracture, neither the surgical (median: 24; 25% percentil: 17; 75% percentil: 44) nor the non-surgical treatment regimen (median: 32; 25% percentil: 13; 75% percentil: 48) demonstrated an advantage over the other (p=0.98).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAt least one sublesional fracture as a secondary condition will occur in between one-third and one-half of individuals with SCI [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTypically, most fractures occur following an accident during a wheelchair transfer, such as into bed, or a fall from the wheelchair [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], as demonstrated in this study.\u003c/p\u003e \u003cp\u003eConsistent with existing literature [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], in this study the majority of fractures were found to occur around the knee joint.\u003c/p\u003e \u003cp\u003eThe optimal treatment of fractures of the long bones presents a significant challenge, particularly when it comes to selecting the appropriate therapeutic regimen, whether conservative or surgical. However, to date, there is no consensus on the optimal treatment of lower extremity fracture complications in patients with an SCI [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eKey aspects in the decision-making process include timely mobilization into a wheelchair, length of hospital stay, and the management and occurrence of complications. To our knowledge, this study represents the largest overview on this topic in recent years.\u003c/p\u003e \u003cp\u003eSeveral studies have suggested that surgical treatment of fractures in SCI patients may expedite post-fracture mobilization [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The results of the fractures included in this study did not confirm this assumption, as the patients took on average 3 days longer to achieve their first mobilization.\u003c/p\u003e \u003cp\u003eThis could be attributed to the fact that most patients initially sought medical attention several days after the trauma and were then transferred to our hospital, missing the optimal window for immediate fracture treatment.\u003c/p\u003e \u003cp\u003eAdditionally, due to the pronounced swelling of the skin and soft tissue, surgery had to be delayed, which may have contributed to the time difference. In some studies in the literature, such as [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], based on a similarly sized patient population, the average hospital stay was reported to be ten days longer. This extended duration may be due in part to the practice of discharging patients only after radiologically confirmed signs of healing, along with the fact that the data are over 30 years old.\u003c/p\u003e \u003cp\u003eThe majority of the conservatively treated intra-articular fractures in this study, particularly those of the proximal tibia and distal femur, exhibited a significantly higher incidence of complications, primarily soft tissue damage to the affected extremity, compared to surgically treated fractures.\u003c/p\u003e \u003cp\u003eThe underlying mechanisms for this association remain unclear in the existing literature. However, the authors of this study hypothesize that intra-articular involvement may contribute to an increase in spasticity, which could, in turn, elevate the risk of pressure-induced soft tissue damage in the presence of an immobilizing cast.\u003c/p\u003e \u003cp\u003eAmong the fractures treated conservatively, nearly 15% occurred in patients with incomplete spinal cord injuries. Given this distribution, it is unsurprising that 8 out of the 9 complications in the conservative treatment group, primarily soft tissue complications, were observed in patients with complete spinal injuries.\u003c/p\u003e \u003cp\u003eThis observation further suggests that, due to the loss of epicritic sensation in the lower extremities, patients classified as ASIA may be particularly vulnerable to complications from non-surgical treatment.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eOne limitation of this study, inherent in its retrospective design, is the absence of radiological follow-up for all patients. As a result, we were unable to assess the extent to which bony consolidation had occurred in the patients included. This factor might have affected the outcome measures, particularly regarding the healing process and the evaluation of the fracture's progression.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn summary, a significantly higher incidence of complications is observed with conservative therapy. Although surgical treatment does not enable individuals with spinal cord injuries to achieve significantly faster mobilization into a wheelchair or a significantly shorter hospital stay, the high incidence of soft tissue complications due to immobilization underscores the necessity of regular and resource-intensive soft tissue monitoring. In particular, fractures with intra-articular involvement appear to be especially at risk for complications. Furthermore, complications were significantly more frequent in patients with complete spinal cord injuries compared to those with incomplete injuries.\u003c/p\u003e \u003cp\u003eGiven the substantial time and nursing resources required for conservative management, and the fact that no cases of symptomatic implant loosening were observed, the authors recommend surgical treatment for fractures of the long bones in the lower extremities to optimize both clinical outcomes and resource allocation.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData Available Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\u003cp\u003e \u003ch2\u003eEthical Approval\u003c/h2\u003e \u003cp\u003e The study has received approval from the Ethics Committee of the State Medical Association of Hesse, with the reference number 2024-3798-evBO.\u003c/p\u003e \u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGifre L, Vidal J, Carrasco J, Portell E, Puig J, Monegal A, u. a. Incidence of skeletal fractures after traumatic spinal cord injury: a 10-year follow-up study. Clin Rehabil. April 2014;28(4):361\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eZehnder Y, L\u0026uuml;thi M, Michel D, Knecht H, Perrelet R, Neto I, u. a. Long-term changes in bone metabolism, bone mineral density, quantitative ultrasound parameters, and fracture incidence after spinal cord injury: a cross-sectional observational study in 100 paraplegic men. Osteoporos Int. M\u0026auml;rz 2004;15(3):180\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003ePelletier CA, Dumont FS, Leblond J, Noreau L, Giangregorio L, Craven BC. Self-report of one-year fracture incidence and osteoporosis prevalence in a community cohort of canadians with spinal cord injury. Top Spinal Cord Inj Rehabil. 2014;20(4):302\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eGarland DE, Adkins RH, Kushwaha V, Stewart C. Risk factors for osteoporosis at the knee in the spinal cord injury population. J Spinal Cord Med. 2004;27(3):202\u0026ndash;6. \u003c/li\u003e\n\u003cli\u003eBattaglino RA, Lazzari AA, Garshick E, Morse LR. Spinal cord injury-induced osteoporosis: pathogenesis and emerging therapies. Curr Osteoporos Rep. Dezember 2012;10(4):278\u0026ndash;85. \u003c/li\u003e\n\u003cli\u003eLazo MG, Shirazi P, Sam M, Giobbie-Hurder A, Blacconiere MJ, Muppidi M. Osteoporosis and risk of fracture in men with spinal cord injury. Spinal Cord. April 2001;39(4):208\u0026ndash;14. \u003c/li\u003e\n\u003cli\u003eFouasson-Chailloux A, Gross R, Dauty M, Gadbled G, Touchais S, Le Fort M, u. a. Surgical management of lower limb fractures in patients with spinal cord injury less associated with complications than non-operative management: A retrospective series of cases. J Spinal Cord Med. Januar 2019;42(1):39\u0026ndash;44. \u003c/li\u003e\n\u003cli\u003eRagnarsson KT, Sell GH. Lower extremity fractures after spinal cord injury: a retrospective study. Arch Phys Med Rehabil. September 1981;62(9):418\u0026ndash;23. \u003c/li\u003e\n\u003cli\u003eGrassner L, Klein B, Maier D, B\u0026uuml;hren V, Vogel M. Lower extremity fractures in patients with spinal cord injury characteristics, outcome and risk factors for non-unions. J Spinal Cord Med. November 2018;41(6):676\u0026ndash;83. \u003c/li\u003e\n\u003cli\u003eAkhigbe T, Chin AS, Svircev JN, Hoenig H, Burns SP, Weaver FM, u. a. A retrospective review of lower extremity fracture care in patients with spinal cord injury. J Spinal Cord Med. Januar 2015;38(1):2\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eBethel M, Bailey L, Weaver F, Le B, Burns SP, Svircev JN, u. a. Surgical compared with nonsurgical management of fractures in male veterans with chronic spinal cord injury. Spinal Cord. Mai 2015;53(5):402\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eCarbone LD, Ahn J, Adler RA, Cervinka T, Craven C, Geerts W, u. a. Acute Lower Extremity Fracture Management in Chronic Spinal Cord Injury: 2022 Delphi Consensus Recommendations. JB JS Open Access. 2022;7(4):e21.00152. \u003c/li\u003e\n\u003cli\u003eSugi MT, Davidovitch R, Montero N, Nobel T, Egol KA. Treatment of lower-extremity long-bone fractures in active, nonambulatory, wheelchair-bound patients. Orthopedics. September 2012;35(9):e1376-1382. \u003c/li\u003e\n\u003cli\u003eBishop JA, Suarez P, DiPonio L, Ota D, Curtin CM. Surgical versus nonsurgical treatment of femur fractures in people with spinal cord injury: an administrative analysis of risks. Arch Phys Med Rehabil. Dezember 2013;94(12):2357\u0026ndash;64. \u003c/li\u003e\n\u003cli\u003eCochran TP, Bayley JC, Smith M. Lower extremity fractures in paraplegics: pattern, treatment, and functional results. J Spinal Disord. 1988;1(3):219\u0026ndash;23. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"spinal-cord","isNatureJournal":false,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"sc","sideBox":"Learn more about [Spinal Cord](http://www.nature.com/sc/)","snPcode":"41393","submissionUrl":"https://mts-sc.nature.com/cgi-bin/main.plex","title":"Spinal Cord","twitterHandle":"@journalsci","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6185684/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6185684/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eStudy Design:\u003c/strong\u003e A 10-year\u003cstrong\u003e \u003c/strong\u003esingle-center retrospective chart review\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective: \u003c/strong\u003eTo evaluate the differences between conservative and surgical treatment of long bone fractures in individuals with chronic SCI, focusing on wheelchair mobilization, overall hospital days, and complication rates.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSetting: \u003c/strong\u003eSpinal cord injury Department, BG Trauma Center Frankfurt am Main, Germany\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThe study, conducted between 2014 and 2023, compared conservative and surgical treatment for long bone fractures in individuals with chronic SCI using descriptive statistics.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eA total of 58 long bone fractures were included, with 31 surgically and 27 conservatively treated. Patient characteristics (age, gender, SCI level, fracture complexity) did not differ between groups (p \u0026gt; 0.05). The median time to first wheelchair mobilization was 14 days for both groups (p = 0.38), and there was no significant difference in hospital stay (p = 0.98). Only one surgically treated case (3.2%) had delayed wound healing, while 9 out of 31 non-surgically treated cases had complications, leading to a significantly higher complication rate for non-surgical treatment (p = 0.002).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eNon-surgical treatment had a higher complication rate than surgical treatment. Both approaches were equivalent in time to first wheelchair mobilization, and neither showed a significantly shorter hospital stay.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSponsorship:\u003c/strong\u003e non\u003c/p\u003e","manuscriptTitle":"Surgical and Conservative Treatment of lower Limb Fractures in Patients with Chronic Spinal Cord Injury","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-31 12:28:58","doi":"10.21203/rs.3.rs-6185684/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"revise","date":"2025-06-17T11:09:18+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"This content is not available.","date":"2025-05-10T18:55:03+00:00","index":2,"fulltext":"This content is not available."},{"type":"reviewerAgreed","content":"This content is not available.","date":"2025-04-27T12:14:55+00:00","index":2,"fulltext":"This content is not available."},{"type":"editorInvitedReview","content":"This content is not available.","date":"2025-04-20T03:41:31+00:00","index":1,"fulltext":"This content is not available."},{"type":"reviewerAgreed","content":"This content is not available.","date":"2025-04-13T02:28:25+00:00","index":1,"fulltext":"This content is not available."},{"type":"reviewersInvited","content":"","date":"2025-03-21T07:32:44+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-17T17:09:52+00:00","index":"","fulltext":""},{"type":"submitted","content":"Spinal Cord","date":"2025-03-16T19:50:52+00:00","index":"","fulltext":""},{"type":"checksFailed","content":"","date":"2025-03-11T16:16:15+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-08T19:35:19+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"spinal-cord","isNatureJournal":false,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"sc","sideBox":"Learn more about [Spinal Cord](http://www.nature.com/sc/)","snPcode":"41393","submissionUrl":"https://mts-sc.nature.com/cgi-bin/main.plex","title":"Spinal Cord","twitterHandle":"@journalsci","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"4d4eaaaf-4fb4-4fec-a6f8-05ee844f14d7","owner":[],"postedDate":"March 31st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":46008617,"name":"Health sciences/Health care/Fracture repair"},{"id":46008618,"name":"Health sciences/Medical research/Outcomes research"},{"id":46008619,"name":"Health sciences/Medical research/Epidemiology"}],"tags":[],"updatedAt":"2025-11-08T08:08:47+00:00","versionOfRecord":{"articleIdentity":"rs-6185684","link":"https://doi.org/10.1038/s41393-025-01138-1","journal":{"identity":"spinal-cord","isVorOnly":false,"title":"Spinal Cord"},"publishedOn":"2025-11-07 05:00:00","publishedOnDateReadable":"November 7th, 2025"},"versionCreatedAt":"2025-03-31 12:28:58","video":"","vorDoi":"10.1038/s41393-025-01138-1","vorDoiUrl":"https://doi.org/10.1038/s41393-025-01138-1","workflowStages":[]},"version":"v1","identity":"rs-6185684","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6185684","identity":"rs-6185684","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}