Combined pudendal and sciatic nerve palsy following intramedullary nailing in fracture shaft femur: a rare case report

Traction tables have been widely used by orthopaedic surgeons for the management of femoral shaft fractures. Although complications associated with their use are uncommon, they can still occur. Among neurological complications, sciatic and pudendal nerve palsies are the most frequently reported. Recognizing the potential causes and analyzing these complications are crucial for raising awareness among surgeons and implementing preventive strategies to enhance patient safety during surgical procedures. A 22-year-old male sustained a comminuted fracture of the left femoral shaft following a road traffic accident. The patient had an intact distal neurovascular status (DNVS) at presentation. Open reduction and internal fixation (ORIF) with femoral interlocking nail (FIN) was done using a traction table. Post-operatively, he developed signs of both sciatic and pudendal nerve palsy. The simultaneous occurrence of pudendal and sciatic nerve palsy is rare. In this case, pudendal nerve palsy was likely caused by prolonged traction with sustained hip adduction throughout the procedure, while sciatic nerve palsy was attributed to postoperative hematoma formation. To minimize such complications, it is advisable to limit soft tissue dissection during femoral shaft fracture reduction and promptly release traction after interlocking screw placement. Additionally, adherence to a "tourniquet safety protocol" that is, releasing traction every 120 minutes in prolonged surgeries can be beneficial. Hip adduction beyond the neutral position should also be avoided to reduce the risk of nerve injury.