Traction-induced Pudendal Nerve Palsy Post Intramedullary Nailing of the Femur

Abstract

Purpose: Pudendal nerve palsy after and intramedullary femur nail is not an uncommon complication. This is due to prolonged traction on the traction table.

Methodology: This report presents a 37-year-old male who sustained a transverse left femur fracture following a motor vehicle accident. The patient underwent an antegrade intramedullary femur nail. At 6 weeks, post-surgery he complained of erectile dysfunction without any apparent medical cause. He was subsequently referred to urology and started on medical treatment after counselling.

Findings: The most likely cause of pudendal nerve palsy in this patient was insufficient muscle relaxation which led to a difficult closed reduction of the fracture and thus a prolonged traction time and increase traction force. Erectile dysfunction is a well-documented complication of traction after femoral nailing. The surgeon and anesthetist needed to put all necessary measures in place to prevent this debilitating complication and the patient must be counselled pre-operatively about this risk. The following strategies have shown to decrease the risk of traction-induced pudendal nerve palsy.

Recommendation: A large diameter, well-padded perineal post should be placed between the genitalia and the non-injured limb. Traction should be limited to the critical operative steps only and adequate muscle relaxant should be given to the patient to decrease the traction force needed.