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C OPYRIGHT Ó 2022 BY T HE J OURNAL OF B ONE AND J OINT S URGERY, I NCORPORATED

Iatrogenic Vertebral Fracture During Intramedullary

Nailing for Femoral Fracture
A Case Report
Yong-Bum Joo, MD, PhD, Woo-Yong Lee, MD, PhD, Young- Mo Kim, MD, PhD, and Byung-Kuk Ahn, MD
Investigation performed at Chungnam National University Hospital, Daejeon, Chungnam, South Korea

Abstract
Case: A 73-year-old woman with advanced ankylosing spondylitis (AS) underwent closed reduction and internal fixation
using antegrade intramedullary nailing because of midshaft fracture of her right femur. After the surgery had been
performed, a fracture and dislocation at T12–L1 was detected. Therefore, emergency spinal decompression and posterior
instrumentation placement from T11 to L5 were then performed.
Conclusion: Patients with advanced AS have a high risk of vertebral fracture, so special care must be taken not to
transmit excessive stress on the spine for surgical reduction and manipulation of the lower extremity.

A
nkylosing spondylitis (AS) is a chronic inflammatory
arthritic disease mainly affecting the spine and sacroiliac
joints, leading to spinal fusion and kyphotic deformity1,2.
Chronic inflammation causes the loss of bone mass and bone
erosion3. Therefore, patients with AS show an increased prevalence
of osteoporosis and significantly lower bone mineral density (BMD)
than other patients without AS3,4. The ankylosed spine in a patient
with AS is particularly susceptible to vertebral fractures due to spinal
rigidity and secondary osteoporosis5. In AS, the spine is unable to
tolerate the load that a normal spine can withstand; therefore, ver-
tebral fractures may occur after relatively minor trauma6. In addi-
tion, these fractures are associated with a high risk of neurological
complications resulting from delayed or missed diagnoses7.
Bisphosphonates (BPs) are taken as a first-line medication in
the treatment of osteoporosis associated with AS8. BPs increase BMD
and decrease the incidence of fragility fractures by inhibiting
osteoclast-mediated bone resorption9. However, BPs also inhibit
bone formation and cause delayed bone healing10. Long-term BP use
for more than 5 years is associated with subtrochanteric and
diaphyseal atypical femoral fractures (AFFs)11. Compared with sub-
trochanteric AFFs, diaphyseal AFFs tend to occur in patients with a
more advanced age, lower BMD, and greater anterolateral femoral
bowing12,13. Currently, intramedullary (IM) nailing is the optimal
surgical method for treating diaphyseal AFFs14. However, in patients
with excessive femoral bowing, several problems, such as intra-
operative iatrogenic cortical fractures, straightening of the femur, leg-
length discrepancy, and problematic bone healing, can occur15.
To the best of our knowledge, there have been no reports
describing iatrogenic vertebral fractures during IM nailing for
AFFs. This case report describes a serious iatrogenic thoraco-
lumbar fracture-dislocation that occurred during IM nailing
for a diaphyseal AFF related to long-term BP therapy in a
patient with advanced AS.
The patient was informed that data concerning the case
would be submitted for publication, and she provided consent.
Case Presentation
A 73-year-old woman presented to the emergency department
with pain in the right thigh and back after slipping and falling
down in the toilet. Physical examination revealed swelling and
tenderness of the right midthigh. She had experienced preexisting
pain repeatedly over 5 months in the right midthigh. The neu-
rological condition and circulation of the lower extremities were
normal. A midshaft fracture was found on plain radiographs of
the patient’s right femur. Lateral cortical thickening of the fracture
site and a short oblique fracture were noted (Fig. 1). Plain radi-
ographs of the lumbar spine showed vertebral body complete
fusion from L1 to L5 and incomplete fusion at L5 S1 with
kyphotic deformity and total ankylosis of both sacroiliac joints.
There was no fracture in the lumbar spine (Fig. 2).
She had been diagnosed with AS at the local clinic in the
past but had not received specific treatment for this disease. She
only took nonsteroidal anti-inflammatory drugs and painkillers
intermittently for her back pain. She had taken BP (alendronate

This work was supported by research fund of Chungnam National University (Daejeon, Chungnam, South Korea).

Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/B942).
Keywords ankylosing spondylitis; iatrogenic vertebral fracture; atypical femoral fracture; intramedullary nailing

JBJS Case Connect 2022;12:e22.00192 d http://dx.doi.org/10.2106/JBJS.CC.22.00192

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Fig. 1
Anteroposterior (Fig. 1-A) and oblique (Fig. 1-B) radiographs of the right femur demonstrated a suspected atypical femoral fracture. Lateral cortical
thickening of the fracture site (white arrow) and a short oblique fracture were noted.

sodium/colecalciferol compound) for 6 years for osteoporosis. The broken femur was stabilized with an antegrade IM
The T-score of her femoral neck on a dual-energy x-ray absorp- nail on day 3 after injury. After general anesthesia, surgery was
tiometry BMD scan was -3.1. In addition, she had taken medi- performed with the patient in the supine position using the
cation for hypertension for 10 years. fracture table. We stabilized the patient to the operating table

Fig. 2
(Fig. 2-A) Anteroposterior radiograph of the lumbar spine showing fusion of the entire spine and total ankylosis of both sacroiliac joints. (Fig. 2-B) Lateral
radiograph of the lumbar spine showing fixed kyphotic deformity.
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Fig. 3
Anteroposterior (Fig. 3-A) and lateral (Fig. 3-B) radiographs of the right femur and anteroposterior radiographs of the pelvis (Fig. 3-C). The broken femur
was stabilized by an antegrade interlocking intramedullary nail. An iatrogenic subtrochanteric fracture of the femur occurred during nail insertion
(white arrow).

with a strap and made a bump using operative drapes beneath

the hip to allow antegrade nailing in a supine position. How-
ever, the spine was not specifically stabilized because the patient
was not on spine precautions at the time of surgery. During
nail insertion, an iatrogenic pertrochanteric fracture occurred
(Fig. 3). However, additional fixation was not needed for the
iatrogenic fracture, and there were no other complications
intraoperatively. She underwent postoperative imaging of the
femur at the radiology department and was then moved to the
ward. She complained of back pain and decreased sensation
and movement in both lower extremities. The motor strength
of both lower extremities was found to be grade zero. The
anal tone was poor, and perianal sensation was lost. Emer-
gency radiography of the spine was performed. On plain
radiography and three-dimensional spine computed tomog-
raphy, transdiscal fracture of T12–L1, including the posterior
vertebral column, and lateral translation of T12-L1 were found
(Fig. 4). Lumbar magnetic resonance imaging showed squeezing
and trapping of the conus medullaris above T12 on L1 due to
the left laminae (Fig. 5). In a retrospective review of the
previous plain radiographs, postoperative chest x-ray after IM
nailing on the femur showed a fracture and dislocation at
T12–L1, which had been undetected to this point (Fig. 4).
Emergency spinal decompression and posterior instrumen-
tation placement from T11 to L5 were then performed. The
surgical approach was performed with a midline posterior
approach, and the patient was lying in the prone position. A
pedicle screw-rod system with cement augmentation for os- Fig. 4
teoporotic bone was used to decompress the spinal canal and Routine chest x-ray performed after intramedullary nailing showing fracture-
stabilized the spine (Fig. 6). dislocation at T12-L1, which was misdiagnosed.
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Fig. 5
Anteroposterior (Fig. 5-A) and lateral (Fig. 5-B) radiographs showing fracture-dislocation of T12-L1 (white arrow). Coronal (Fig. 5-C) and sagittal (Fig. 5-D)
magnetic resonance images showing transdiskal fracture-dislocation of T12-L1, including the posterior vertebral column, and lateral translation of T12 on
L1. The conus medullaris was squeezed between T12 and L1 (arrowhead).

Fig. 6
Postoperative anteroposterior (Fig. 6-A) and lateral (Fig. 6-A) radiographs of the lumbar spine showing reduction of the fracture-dislocation and posterior
instrumentation from T11 to L5.
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Mobilization in a thoracolumbar orthosis brace was ini-
tiated on postoperative day 1, and the brace was worn for
12 weeks in total. Rehabilitation began immediately and con-
sisted of education and physical therapy. Two years after spinal
surgery, the patient continues to receive rehabilitation on an
ongoing basis. However, her neurological status has still not
significantly improved. At the most recent follow-up, bony
consolidation was observed at the femur (Fig. 7).
Discussion
T he incidence of vertebral fractures in patients with AS has
been reported to range from 10% to 43%3. Osteoporotic
bone and spinal rigidity are risk factors of vertebral fracture in
AS1,3,16. The prevalence of vertebral fracture increases gradually
with time after AS diagnosis, and such fractures can take an
average of 20 years to occur after the onset of AS17. In addition,
most fractures (51.7%) occur after the age of 70 years18. In our
case, the patient was 73 years and diagnosed with AS 15 years
earlier. Vertebral fractures can occur after trivial trauma or even
without obvious trauma16,19. Hospital bed transfers, slips, and
low-energy ground-level falls could cause vertebral fracture in
patients with AS19. The risk of vertebral fracture in patients with
AS is 2- to 8-fold higher than that in patients without AS3,20
because osteoporosis is more prevalent in these patients than in
the normal population and the spine in AS is abnormally rigid
because of ligament ossification5,16. In particular, the ossifica-
tion process involves the disk and endplates, resulting in re-
modeling of the vertebral body to create a squared vertebra,
referred to as a bamboo spine16,21. Unlike normal flexible ver-
tebrae, those in AS cannot dissipate traumatic energy into the
surrounding soft tissue, so the energy is instead absorbed into
the bony structure of the spine22. Progressive remodeling of the
vertebral column results in fixed kyphotic deformities, and
such positive sagittal alignment increases the risk of fracture16,20.
Vertebral fractures are highly unstable because they usually
Fig. 7
Anteroposterior (Fig. 7-A) and lateral (Fig. 7-B) radiographs of the right femur at 6 months after surgery. Bony consolidation was observed at the femur.
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involve all 3 spinal columns. In addition, these fractures are
often missed or delayed in diagnosis. Therefore, complete
spinal cord injury is more common in patients with AS than in
patients with a normal mobile spine3,16.
In this case, the patient had all the risk factors described
above and was, therefore, particularly vulnerable to vertebral
fracture. The initial diagnosis was a suspected AFF associated
with long-term BP intake. In fact, the patient had taken BPs for
6 years as a treatment of osteoporosis. Iatrogenic femoral
fracture can occur during IM nailing for AFFs associated with
anterolateral bowing15. In our case, iatrogenic fracture occurred
in the subtrochanteric region of the femur, which could be
found on C-arm examination during surgery. However, ver-
tebral fracture was not detected during surgery.
This is the first report of an iatrogenic vertebral fracture
occurring during IM nailing for an AFF in a patient with AS.
However, there have been 4 reports on iatrogenic vertebral
fractures after lower extremity surgery in patients with AS
(Table I)19,23-25. Jung et al. reported an iatrogenic vertebral
fracture occurring after IM nailing for a femoral fracture in an
85-year-old woman with AS23. In the case report, the patient
complained of complete paraplegia 12 hours after surgery23.
Conus medullaris syndrome occurred because of aggravation
of the fracture-dislocation at T12-L1 that existed before sur-
gery23. In addition, there have been 3 reports on iatrogenic
vertebral fractures occurring after total hip arthroplasty (THA)
in patients with AS19,24,25. Danish et al. described the cases of 2
morbidly obese patients with AS who underwent THA and
experienced iatrogenic, intraoperative T11 hyperextension
fractures, resulting in acute traumatic paraplegia19. There were
no complications intraoperatively, but immediately after sur-
gery, the patients complained of weakness in both lower
extremities19. Mahesh et al. described cauda equina syndrome
due to L2-3 fracture-dislocation after THA in a 25-year-old
woman with AS24. There were numbness and muscle weakness
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TABLE 1 Summary of Reported Cases of Iatrogenic Vertebral Fracture During Lower Extremity Surgery in Patients With Ankylosing Spondylitis.

Author Primary Surgery, Iatrogenic

(Published Patient’s Intraoperative Vertebral Neurologic
year) Age, Sex Position Fracture Symptoms Treatment Outcome

Danish et al. 59, THA, supine T11-12 extension T11 sensory level T11-12 posterior Bilateral anterior tibialis and
(2008) female fracture with ASIA C decompression gastrocnemius: Grade 3,
dislocation paraplegia and T9-L2 poste- quadriceps: Grade 1
rior fusion
Danish et al. 60, male THA, supine T10-11 extension T11 sensory level T11 posterior No neurological recovery
(2008) fracture with ASIA B decompression
paraplegia and bracing
Jung et al. 85, Intramedullary T12-L1 extension Conus medullaris T11-L3 posterior No neurological recovery
(2020) female nailing, supine fracture syndrome lumbar interbody
dislocation fusion
Mahesh et al. 25, THA, supine L2-3 extension Cauda equina Posterior decom- No neurological recovery
(2008) female fracture syndrome pression and
dislocation T12-L4
instrumentation
Pitta et al. 68, THA, supine L4-5 extension Paresthesia, poor L3-S1 posterior Revision spinal surgery for
(2017) female fracture proprioception, decompression fixation loss,
dislocation weakness in L4 with L2 pelvis Improved strength, sensa-
nerve distribution posterior fusion tion, but residual weakness
in the tibialis anterior
bilaterally

ASIA = American Spinal Injury Association, THA = total hip arthroplasty.

on the morning of the second day after surgery in the patient’s the stress was concentrated at the point of lowest resistance in
both lower extremities24. Finally, Pitta et al. described the case T12–L1, which may have resulted in a fracture because of no
of a 68-year-old man who underwent THA with AS and sus- motion segments in her spine. (Fig. 8). Meanwhile, when
tained an L4-5 extension fracture-dislocation with neural antegrade IM nailing is performed in the supine position, it is
deficits25. There were no specific complications during the important to adduct the trunk from the ipsilateral hip to ensure
surgery, and the patient experienced paresthesia and poor that the nail is inserted at the proper angle27. To achieve this, it is
proprioception 2 days postoperatively25.
The cause of the iatrogenic vertebral fracture in all the
above cases was related to the inappropriate posture of the
patients during the surgery. Patients with advanced AS cannot
be positioned fully supine because of thoracic kyphosis19.
Therefore, supine positioning without upper back support for
maintaining a preexisting spinal curve results in hyperexten-
sion spinal injury23. The weight of the upper and lower bodies
can each act as a lever on the cranial and caudal portions of the
rigid spine, causing the fracture to open ventrally19,24,26. In our
case, we hypothesized that the vertebral fracture-dislocation
was caused by stress concentration at T12-L1 during the AFF
fixation surgery. The patient had a history of lying on its lateral
side for many years before admission. The supine position may
not have been possible because of her kyphotic and stiff spine.
A fracture table was used with the patient lying in the supine
position, and her upper back was supported with a pad to Fig. 8
maintain the preexisting kyphotic curvatures. During the Possible mechanism of fracture-dislocation at T12-L1 in this case. The
operation, when the traction force for fracture reduction was patient could not lie on her back because of kyphosis of the spine. When
applied to the lower extremity, distraction forces were trans- traction force (white arrow) was applied to the lower limb for the purpose of
mitted to the anterior column of the spine, and compressive fracture reduction, excessive distraction forces (black arrow) were applied
forces were transmitted to the posterior column. In this state, to the anterior column.
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Fig. 9
Possible mechanism of fracture-dislocation at T12-L1 in this case. Lateral
bending force (black arrow) was applied to the upper trunk because the
insertion angle of the intramedullary nail was unsecured because of the
patient’s fused spine.
necessary to bend the upper trunk 10° to 15° to the contra-
lateral side27. In our case, a strong lateral push was applied to
the upper trunk because the angle of insertion was unsecured
during nail insertion because of the rigid spine of the patient.
This forceful maneuver may have been the cause of the lateral
dislocation of T12 on L1 (Fig. 9).
When antegrade IM nailing is performed on a fracture
table, the supine and lateral positions can be used. However, the
supine position is more universal27. It provides easier access for
the anesthesiologist, and the surgeon is also more comfortable
with the patient in this position. However, in our case, because
the patient could not lie on her back, the lateral position may
have been more appropriate and safer.
The nail type and starting point used with IM nailing are
critical in maintaining fracture reduction and can contribute to
intraoperative peri-implant fracture. This is particularly true in
the setting of osteoporosis and in patients with an atypically
small radius of curvature28. Both greater trochanter (GT) and
piriformis fossa (PF) starting points are used in antegrade nailing
of femoral shaft fractures. Kumar et al. suggested GT entry nails
to be superior to PE nails for treating shaft-of-the-femur frac-
tures in adults given a shorter learning curve and better func-
tional outcomes and the close proximity of structures to PF
starting points such as the medial femoral circumflex artery;
however, the rates of union are comparable in both29,30.
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spine for surgical reduction and manipulation of the lower
extremity. n
Yong-Bum Joo, MD, PhD
Woo-Yong Lee, MD, PhD
Young- Mo Kim, MD, PhD
Byung-Kuk Ahn, MD
Department of Orthopedic Surgery, Chungnam National University
Hospital, Chungnam National University School of Medicine, Daejeon,
South Korea
E-mail address for W.-Y. Lee: studymachine@daum.net
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