Abstract
INTRODUCTION: Lower extremity fractures are a frequent complication in patients with chronic spinal cord injury due to significant bone mineral density loss and altered bone metabolism. While non-operative management has traditionally been favored, advances in surgical techniques have expanded treatment options, including intramedullary nailing and plate fixation. However, the optimal approach remains controversial, especially in paraplegic patients with distal femoral fractures. This case report highlights the challenges and complications associated with surgical management in this unique patient population. CASE REPORT: A 45-year-old male with T2 paraplegia presented with bilateral distal femoral shaft fractures following a motor vehicle accident. He underwent bilateral retrograde intramedullary nailing to preserve mobility and independence. Postoperatively, the patient developed a hypertrophic non-union on the right side with hardware migration, requiring revision with plate and screw fixation. Subsequently, he developed painful hardware on the right and severe heterotopic ossification on the left, significantly impacting his quality of life. Although hardware removal was recommended, the surgeries were never performed due to the patient's clinical course and eventual death from unrelated causes. CONCLUSION: Clinicians should be aware of the potential complications associated with intramedullary nailing and revision open reduction internal fixation in paraplegic patients who present with bilateral distal femoral shaft fractures. Treatment remains controversial and should be tailored to each patient.