1. Injury Considerations in Adaptive Sports David M Popoli, MD

2. Prelude

3. By the Numbers <5% 33% vs. 0.6% 12.8% vs. 72.1%
<5% -- percentage of adults who participate in 30 minutes of physical activity each day
33% -- percentage of adults who receive the recommend amount of physical activity each week – 150 minutes
0.6% -- percentage of adults with a disability who receive the recommend amount of physical activity each week.
75.6% -- percentage of persons with a disability reported being physically inactive during a usual week
12.8% -- percentage of persons without a disability who reported being physically inactive during a usual week.
*U.S. Department of Health and Human Services. Healthy People 2010.

4. FES Rowing

5. The Case 44 yo FES rower, normal state of health T4 paraplegia
“Feeling 3min into exercise
Resolves with discontinuing exercise

6. Differential Dehydration Hypoglycemia Hypotension
Electrolyte disturbance
Arrhythmia
Autonomic dysreflexia

7. Quick Triage Recent illness -- ? dehydration/hypotension
Recent travel -- ? dehydration/hypotension
Ate snack after work
? Lytes
? AD
SBP 200s, HR 40s, flushing
No arrhythmia

8. Autonomic Dysreflexia
Bladder
Bowel
Skin
Bladder #1 – usually bladder distention, but also consider UTI, stones
Bowel – distention, bowel program, hemorrhoids, fissure
Skin – constricting clothing, pressure ulcer, blister/burn, ingrown toenails

9. Initial Management Sit up Screen clothing, shoes, skin, bladder, bowel
Other thoughts?
Up to induce hypotension
No tight clothing items, no bands, shoes ok, no pressure ulcers, friction burngs, bladder not distented, bowel regiment normal

10. Other causes? Scrotal compression Exercise-induced AD* Trauma?
Recently traveled and “cracked my knee on a transfer.”
Bone mineral density loss can be significant, up to 6-8% per year after injury, generally
*Ashley et al. Evidence of autonomic dysreflexia during functional electrical stimulation in individuals with spinal cord injuries. Paraplegia (1993) 31, 593–605; doi: /sc

11. Treatment
Non-operative
Traditional repair
LISS

12. Non-Operative vs. Traditional
Non-operative management = bulky dressing with posterior splint, then early ROM to avoid complications with decreased knee ROM that would affect sitting. Anatomical alignment less important because no weight bearing. + no surgery, no risk of hardware issues/osteomyelitis. - risk of non-union, skin infections, frequent dressing changes, limited activity, ? Decreased knee ROM versus repair
Traditional operative repair = retrograde intramedullary nail + bilcortical screws. + improved alignment, higher rate of union, fewer skin infections – surgery, risk of operative infection, risk of revision
Cass, J. Operative Versus Nonoperative Management of Distal Femur Fracture in Myelopathic, Nonambulatory Patients. Orthopedics
Nov 2008; 31 (11).
Hierholzerj et al. Outcome analysis of retrograde nailing and less invasive stabilization system in distal femoral fractures: A retrospective analysis. IJO 2001; 45 (3):

13. Less-Invasive Stabilization System
Plating techniques generally were frowned upon because of reduced bone quality. Plate locking often loosened.
Performance on KOOS similar to femoral nail, complication rates equal (or slightly lower in some studies)
New technique with some serious benefits – lateral approach, no intraarticular issues, unicortiacal screws stay away from blood supply, earlier stability = earlier mobilization.
*Badke et al. Treatment of Distal Femoral Fractures with the Less Invasive Stabilization System (LISS) in Paraplegics. Eur J Trauma 2005; 5:

14. Take Home Keep AD in your mind Get to the bottom of AD
Considerations for bone health

15. Thank You