The Pathophysiology, Identification and Management of Fracture Risk, Sublesional Osteoporosis and Fracture among Adults with Spinal Cord Injury

Beverley Catharine Craven, Christopher M. Cirnigliaro, Laura D. Carbone, Philemon Tsang, Leslie R. Morse

Research output: Contribution to journalReview articlepeer-review

1 Scopus citations


Background: The prevention of lower extremity fractures and fracture-related morbidity and mortality is a critical component of health services for adults living with chronic spinal cord injury (SCI). Methods: Established best practices and guideline recommendations are articulated in recent international consensus documents from the International Society of Clinical Densitometry, the Paralyzed Veterans of America Consortium for Spinal Cord Medicine and the Orthopedic Trauma Association. Results: This review is a synthesis of the aforementioned consensus documents, which highlight the pathophysiology of lower extremity bone mineral density (BMD) decline after acute SCI. The role and actions treating clinicians should take to screen, diagnose and initiate the appropriate treatment of established low bone mass/osteoporosis of the hip, distal femur or proximal tibia regions associated with moderate or high fracture risk or diagnose and manage a lower extremity fracture among adults with chronic SCI are articulated. Guidance regarding the prescription of dietary calcium, vitamin D supplements, rehabilitation interventions (passive standing, functional electrical stimulation (FES) or neuromuscular electrical stimulation (NMES)) to modify bone mass and/or anti-resorptive drug therapy (Alendronate, Denosumab, or Zoledronic Acid) is provided. In the event of lower extremity fracture, the need for timely orthopedic consultation for fracture diagnosis and interprofessional care following definitive fracture management to prevent health complications (venous thromboembolism, pressure injury, and autonomic dysreflexia) and rehabilitation interventions to return the individual to his/her pre-fracture functional abilities is emphasized. Conclusions: Interprofessional care teams should use recent consensus publications to drive sustained practice change to mitigate fracture incidence and fracture-related morbidity and mortality among adults with chronic SCI.

Original languageEnglish (US)
Article number966
JournalJournal of Personalized Medicine
Issue number6
StatePublished - Jun 2023

Bibliographical note

Funding Information:
Craven acknowledges grant support from CIHR, Ontario Ministry of Health and Long-Term Care, PVA Education Foundation, Praxis Spinal Cord Institute and Craig H Nielsen Foundation. Craven was the panel chair for the PVA Bone Health Guideline and is the current Chair of the Canadian Spinal Cord Injury- Rehabilitation Institute and a member of the Osteoporosis Canada Scientific Advisory Committee. Morse reports no conflict of interest and is currently receiving funding from MN State Department of Education, NIDILRR, PVA, and CHNF.

Funding Information:
Craven wishes to acknowledge the UHN Foundation’s support as the University of Toronto/Toronto Rehabilitation Institute Chair in SCI Rehabilitation Research. Morse wishes to acknowledge the funding from NIDILRR, Department of Health and Human Services, 90SIMS0008-01-00 (Morse PD). Tsang wishes to acknowledge fellowship funding from UHN Foundation/SCI Ontario. Carbone wishes to acknowledge funding from the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development (VA IIR 15-294: Best Practices for Management of Fractures in Spinal Cord Injuries and Disorders).

Publisher Copyright:
© 2023 by the authors.


  • dietary supplements
  • drug therapy
  • fractures
  • osteoporosis
  • rehabilitation
  • spinal cord injuries

PubMed: MeSH publication types

  • Journal Article
  • Review


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