Retrospective Analysis of Fractures and Factors Causing Ambulation Loss After Lower Limb Fractures in Duchenne Muscular Dystrophy

Abstract

Objective Prevalence and characteristics of fractures and factors related to loss of ambulation after lower limb fractures were investigated. Design Chart review included height, weight, dual-energy x-ray absorptiometry, corticosteroid use, vitamin D, fracture history, muscle strength, range of motion, and timed performance tests (10 meter walk/run, Gowers, and four steps). Patients were grouped by fracture location and ambulation loss after fracture. Results Two hundred eighty-seven patients with Duchenne muscular dystrophy were identified, 53 of these had experienced fracture. Eighty-one percent were older than 9 yrs at first fracture and 36.4% became nonambulatory after fracture. Dorsiflexion range of motion (fracture side, P = 0.021), quadriceps strength (right side, P = 0.025), and shoulder abduction strength (right, left, and fracture side; P = 0.028, P = 0.027, and P = 0.016) were significantly different within the groups. Patients who became nonambulatory after fracture initially had less dorsiflexion (right, left, fracture side; 2.250 vs. −7.290, P = 0.004; 2.670 vs. −120, P = 0.001; and 2.410 vs. −7.420, P = 0.002) and slower 10-meter walk/run times (7.43 secs vs. 14.7 secs, P = 0.005). Conclusions Fracture represents a significant risk in patients with Duchenne muscular dystrophy; both slower walking speed and ankle contracture confer an increased risk of ambulation loss after fracture. To Claim CME Credits Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME Objectives Upon completion of this article, the reader should be able to: (1) Identify the main factors that are associated with ambulation loss after fracture in patients with Duchenne muscular dystrophy; (2) Identify the risk of fracture in the Duchenne muscular dystrophy population; and (3) Articulate the characteristics associated with fracture in patients with Duchenne muscular dystrophy. Level Advanced. Accreditation The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Fracture risk and impact in boys with Duchenne muscular dystrophy: A retrospective cohort study

“…An increased rate of decline in NSAA scores in boys with a history of fracture compared to those with no fracture was seen. This supports evidence of significant function and ambulation loss after particularly lower limb fractures in boys with DMD, 24,25 While there are likely patient inherent factors that affect fracture recovery, 24 fracture management should aim to minimize prolonged immobilization and promote early rehabilitation. Regular post‐fracture assessments may also help monitor clinical progression and allow for future studies of maintaining independent mobility for longer after major fractures.…”

The Relationship between Obesity and Clinical Outcomes in Young People with Duchenne Muscular Dystrophy

“…In those with obesity and/or those taking steroids, there is a need for close surveillance of fracture risk factors such as vitamin D deficiency, low dietary calcium intake and falls. Dietitians and physiotherapists play an integral role in advising families on how to mitigate these risk factors to help prevent fractures, which causes a significant burden and can lead to loss of ambulation and decline in function and strength [43].…”

Flexible intramedullary nailing for supracondylar femoral fractures in children with Duchenne muscular dystrophy

“…Muscle weakness secondary to the perioperative immobilization and his ankle contracture likely played a negative role. In a recent analysis [ 25 ], patients who became nonambulatory after lower extremity fractures in DMD, initially had slower walking speeds and less ankle dorsiflexion. Other factors like pain threshold and psychological factors should be considered too.…”