Why is traction a precaution in someone on prolonged corticosteroid (steroid) use?

From the Guidelines

Traction is a precaution in patients on prolonged steroid use because steroids can cause osteoporosis, making bones fragile and susceptible to fractures. When a patient has been on steroids like prednisone, dexamethasone, or methylprednisolone for months or years, their bone density decreases significantly, as noted in the 2017 American College of Rheumatology guideline for the prevention and treatment of glucocorticoid-induced osteoporosis 1. This occurs because steroids inhibit calcium absorption, increase calcium excretion, and reduce bone formation while enhancing bone resorption. If traction is applied to these patients, the weakened bones may not withstand the mechanical forces, potentially leading to fractures, especially in weight-bearing bones like the spine, hips, and long bones.

According to the British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults, published in 2019, patients on long-term steroids should have their bone mineral density assessed by bone densitometry, and those with a high FRAX score or risk factors should receive bone density monitoring, calcium and vitamin D supplementation, and possibly bisphosphonates to mitigate steroid-induced bone loss 1. The risk increases with higher steroid doses, longer duration of use, and in elderly patients or those with other risk factors for osteoporosis.

Key considerations for managing patients on prolonged steroid use include:

• Assessing bone mineral density and FRAX score to determine the risk of osteoporotic fractures
• Providing calcium and vitamin D supplementation to all patients starting corticosteroids
• Considering bisphosphonate therapy for patients with a high risk of fracture
• Monitoring bone density regularly in patients on long-term steroids
• Adjusting the FRAX score according to the dose and duration of corticosteroid use, as the standard FRAX score may underestimate the risk in patients taking higher doses of steroids 1.

Healthcare providers should consider alternative immobilization methods or use minimal traction forces when absolutely necessary to minimize the risk of fractures in patients on prolonged steroid use. Additionally, the British Society of Gastroenterology guidelines recommend that patients with a high FRAX score or those receiving prolonged or repeated courses of oral corticosteroids should have their bone mineral density assessed by bone densitometry 1.

From the FDA Drug Label

Corticosteroids decrease bone formation and increase bone resorption both through their effect on calcium regulation (i.e., decreasing absorption and increasing excretion) and inhibition of osteoblast function. To minimize the risk of glucocortoicoid-induced bone loss, the smallest possible effective dosage and duration should be used.

Traction is a precaution in somebody on prolonged steroid use because prolonged steroid use can lead to bone loss and osteoporosis. The use of corticosteroids can decrease bone formation and increase bone resorption, making bones more susceptible to fractures and other injuries.

• Bone loss is a significant concern with prolonged steroid use, and traction may exacerbate this condition.
• Osteoporosis can increase the risk of fractures, and traction may further compromise bone integrity. As a result, caution should be exercised when using traction in patients on prolonged steroid therapy to avoid exacerbating bone loss and osteoporosis 2 2.

From the Research

Traction Precaution in Prolonged Steroid Use

• Traction is a precaution in somebody on prolonged steroid use due to the increased risk of osteoporosis and fractures associated with long-term steroid use 3.
• Steroid-induced osteoporosis can lead to bone loss, making bones more susceptible to fractures, and traction can exacerbate this condition.
• Studies have shown that bisphosphonates can be effective in preventing and treating steroid-induced osteoporosis, reducing the risk of vertebral fractures 3, 4.
• However, the use of bisphosphonates may not completely eliminate the risk of fractures, and precautions such as traction should still be taken to minimize the risk of injury.

Risk of Fractures

• The risk of fractures is a significant concern in individuals on prolonged steroid use, with vertebral fractures being a particular concern 3.
• Studies have shown that bisphosphonates can reduce the risk of vertebral fractures by up to 43% 3.
• However, the risk of nonvertebral fractures may not be significantly reduced by bisphosphonates, highlighting the need for continued precautions such as traction 3.

Bone Mineral Density

• Bone mineral density (BMD) is an important factor in determining the risk of fractures in individuals on prolonged steroid use 5, 6.
• Studies have shown that bisphosphonates can increase BMD, reducing the risk of fractures 3, 6.
• However, the effects of bisphosphonates on BMD can vary depending on the specific medication and dosage used, as well as individual patient factors 5, 6.