Fragility Fractures of the Femur in Spinal Cord Injury Patients

Individuals with spinal cord injury (SCI) experience rapid and profound bone loss below the level of injury, predisposing them to fragility fractures. Due to their frequency and clinical impact, femoral fragility fractures in SCI patients require special consideration. This literature review aims to summarize the current evidence on the epidemiology, pathophysiology, diagnosis, management, and prevention of femoral fragility fractures in SCI patients. A comprehensive literature search was conducted in Medical Literature Analysis and Retrieval System Online (MEDLINE) and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. Studies focusing on femoral fractures in adults with SCI were included, while reviews, pediatric studies, animal studies, and non-English publications were excluded. Femoral fractures account for up to 61% of lower limb fractures in the SCI population, with the distal femur and hip being the most common sites. Risk factors include age, time since injury, motor-complete injuries, and low bone mineral density (BMD). Loss of BMD occurs rapidly after SCI and plateaus two to five years post-injury. Clinical presentation may be subtle, often requiring high suspicion and imaging. Operative management is favored over conservative approaches due to lower complication and non-union rates. Preventive strategies include early BMD assessment, vitamin D and calcium optimization, weight-bearing therapy, and pharmacologic agents such as bisphosphonates and denosumab. Femoral fragility fractures are among the most common and clinically significant complications in patients with SCI. Timely diagnosis, appropriate surgical management, and targeted prevention strategies are critical to reducing complications and maintaining function. There is a need for consistent screening protocols and further research to optimize care in this vulnerable population.