Bone fractures from generalized convulsive seizures and status epilepticus—A systematic review

Abstract

Objective We present a systematic review of the literature regarding types and anatomic distribution of fractures in association with generalized convulsive status epilepticus (GCSE) and convulsive seizures in adult patients accompanied by an illustrative case of a patient with GCSE and diffuse postictal pain from underlying bone fractures. Methods The library search engines PubMed and EMBASE were screened systematically using predefined search terms. All identified articles written in English were screened for eligibility by two reviewers. The preferred reporting items for systematic reviews and meta‐analyses guidelines were followed. Results The screening of 3145 articles revealed 39 articles meeting the inclusion criteria. Among all fractures, bilateral posterior fracture‐dislocations of the shoulders were reported most frequently (33%), followed by thoracic and lumbar vertebral compression fractures (29%), skull and jaw fractures (8%), and bilateral femoral neck fractures (6%). Risk factors for seizure‐related fractures are seizure severity, duration of epilepsy, the use of antiseizure drugs known to decrease bone density, and a family history of fractures. Based on these findings, a three‐step screening procedure is proposed to uncover fractures in the postictal state. All studies were retrospective without standardized screening methods for seizure‐associated fractures resulting in a very low level of evidence and a high risk of bias. Significance Posterior fracture‐dislocations of the shoulders, thoracic and lumbar vertebral compression, fractures of the skull and jaw, and bilateral femoral neck fractures are most frequently reported. Preventive measures including bone densitometry, calcium/vitamin D supplementation, and bisphosphonate therapy should be reinforced in epilepsy patients at risk of osteoporosis. As long as the effect of standardized screening of fractures is not investigated, it is too early to integrate such a screening into treatment guidelines. In the meantime, clinicians are urged to heighten awareness regarding seizure‐associated fractures, especially in patients with postictal pain, as symptoms can be unspecific and misinterpretation may impede rehabilitation.

Risk incidence of fractures and injuries: a multicenter video-EEG study of 626 generalized convulsive seizures

“…Our findings are in line with other studies reporting increased risk of injuries and fractures in epilepsy patients compared to control patients [18][19][20][21][22]. Grzonka et al performed a systematic review of bone fractures from GCSs and status epilepticus, including 39 studies and case reports [23]. They concluded that among all reported fractures, bilateral posterior fracture-dislocations of the shoulders (33%), thoracic and lumbar vertebral compression fractures (29%), skull and jaw fractures (8%), and bilateral femoral neck fractures (6%) were the most common fracture locations [23].…”

“…Grzonka et al performed a systematic review of bone fractures from GCSs and status epilepticus, including 39 studies and case reports [23]. They concluded that among all reported fractures, bilateral posterior fracture-dislocations of the shoulders (33%), thoracic and lumbar vertebral compression fractures (29%), skull and jaw fractures (8%), and bilateral femoral neck fractures (6%) were the most common fracture locations [23]. Vertebral compression fractures were reported in eight (5.2%) out of 153 cases for thoracic, and in six (1.2%) out of 511 cases for lumbar locations.…”

“…Recognition of fractures can be challenging, as symptoms may be misinterpreted as muscle pain, or as emerging rhabdomyolysis after a seizure or status epilepticus, and studies about injuries related to GCSs may be affected both by underreporting and by lack of awareness [23,29]. Grzonka et al suggested a three-step screening procedure to identify fractures related to seizures.…”

“…Second, clinical examinations should look for the presence of fractures by palpation of specific risk locations, and check for deformities, limited joint mobility, and bruising. Third, imaging of areas under suspicion should be performed [23]. Such recommendations mirror our own clinical approach, and may have resulted in the substantial number of vertebral compression fractures that were uncovered by computed tomography and magnetic resonance imaging.…”

Simultaneous Bilateral Neck of Femur Fracture in a Young Adult with Underlying Metabolic Disturbances

“…This would explain this abnormal The strong muscle contractions during seizure attacks can cause fractures and dislocations with a rate of 1% [14]. Bilateral neck of femur fractures compromised 6% of the fractures that occur after generalized seizures [15]. Nevertheless, sustaining bilateral neck of femur fracture after a single convulsion should raise the suspicion of underlying bone disease.…”