Medically Speaking - Common orthopaedic complications in spinal cord injury
Spinal cord injury is a devastating injury and one that normally has far reaching effects on the individual. The lives of spinal cord injured persons are fraught with many complications. In this issue we shall be looking at the possible orthopaedic complications that anyone suffering a spinal injury may develop. Many of these complications can also be found in other disabled persons.
Contractures are probably the most common of all the orthopaedic complications seen. Contractures are the shortening of the tendons in the paralysed joints. A contracture at any joint will present with the inability to place that joint through its normal range of motion. Contractures result from two main reasons (or perhaps a combination of the two).
- If a patient suffers from severe spasticity, contractures may be inevitable. Spasticity problems should preferably be addressed before contractures become evident.
- Lack of daily passive stretches. All paralysed joints should be stretched on a daily basis to prevent shortening. This can be done either by yourself if you are paraplegic, or if tetraplegic, then you would have to rely on a care giver to do this for you.
Contractures can be problematic for a number of reasons. Firstly they may interfere with posture – for example shortening at the achilles tendon (ankles) can lead to the inability to place the feet on the foot plates of the wheelchair resulting in potential injury with the feet slipping off the footplates. Secondly severe contractures may interfere with hygiene and result in dampness and build-up of dirt in the affected crease and this will result in skin infections and bad odour. Finally contractures will affect the ability to participate in functional activities such as dressing – this occurs when there are severe contractures of the elbows, hands and hips.
When contractures are severe and result in some or all of the above problems surgery is then indicated. Prevention is better than cure!
Another common complication is fracture. Spinal cord injured individuals become rapidly osteoporotic – losing calcium from the bones and resulting in brittle bones. These fractures normally occur in the long bones of the leg. A simple transfer where the limb is inadvertently injured against an object may easily result in such a fracture. An audible crack is often heard and this is followed by swelling and redness as well as an increase in spasm. An x ray should be done to exclude a fracture – if there is a fracture, treatment is either by conservative means or surgery.
Overuse syndromes of the upper limbs are also seen in wheelchair users. The upper limbs are used to propel the wheelchair and to assist with lifting and transfer. Continuous use of the upper limbs for the above reasons results in painful inflammation at the elbow (tennis elbow), wrist (carpal tunnel syndrome) or the shoulders (rotator cuff syndrome). Treatment ranges from conservative – the use of oral anti-inflammatory medications, physiotherapy, steroid injections or if all else fails, surgery.
Heterotopic ossification or myositis ossificans (boning) is the laying down of bone outside of the bony skeleton – mainly in the muscle and tendons around the joint and commonly the site is at the hips. In the patient that has some sensation he or she may complain of a warm, tender, firm swelling in a muscle and decreased range of motion in the joint served by the muscle involved. Normally, however, care givers or the patient will notice a decreased range of motion of the joint affected.
Progressive boning can cause serious problems with seating, especially when it affects the range of motion of the hips and or knees. In spinal cord injuries, boning only affects the joints below the level of the injury. The event can also be triggered by chronic infection of a pressure sore overlying a joint such as a hip. If the boning is severe surgery is then indicated.
Scoliosis. Scoliosis in common is paralysis. This is the curvature of the spine in the paralysed part of your body. Scoliosis can either be mobile, in which case nothing more than careful posture and lateral side supports are required, to a fixed scoliosis which results in very poor postures in extreme cases and ongoing issues with pressure sores. Corrective surgery may be indicated.
Osteo arthritis (OA). Any person, especially the elderly suffer from osteo arthritis. This degenerative disease results in pain at the affected joints. In spinal injuries where there is a complete lesion, this is normally not a problem. But in incomplete lesions poor gait and weakness may result in abnormal wear and tear on the joints leading to accelerated OA. Management is normally with chronic ongoing use of anti imflammatories although some orthopaedic surgeons would recommend the use of tablets to help assist in the preservation and possible rebuilding of cartilage although the potential to do this is controversial.
Should you be experiencing any of these problems a visit to your rehabilitation doctor for advice is recommended.