After skeletal traction was placed, repeat radiographs of the pelvis including AP (Figure 3), inlet, outlet, and Judet views were obtained. The right hemipelvis appeared overreduced, but the skeletal traction weight was not adjusted. Nursing staff notified the orthopaedic team that the patient had complete numbness and paralysis of the right foot approximately 4 hours after traction was placed. A physical examination confirmed the nurse's finding, and strong palpable pulses remained in the foot during this time. In an attempt to maintain reduction, but alleviate symptoms, the weight was decreased to 9.1 kg (20 lbs). Sensation of the right foot was re-evaluated, and the patient had minor sensation return throughout the foot, without a specific dermatomal distribution. Motor testing showed complete paralysis of the foot, except for a voluntary muscle twitch of the tibialis anterior. Skeletal traction was then discontinued.
The patient was taken to surgery later that day for open reduction and internal fixation of the anterior pelvic ring with a posterior percutaneous sacroiliac screw. The following day, his vertebral fractures were stabilized with posterior spinal fusion from T11 to L3. He was unable to be extubated for several weeks. After extubation, his neurovascular status of the right lower extremity did not change. He continued to have vague, nonspecific decrease in sensation and no motor activity below the right knee.
Multiple attempts were made to have the patient follow-up with our clinic, but he preferred his orthopaedic care closer in proximity to his home. He is 1 year from his injury, and telephone contact only indicates that he has had continued foot problems. He has refused further contact from our clinic despite attempts to obtain outpatient clinic notes and electromyography results.
Many documented neurologic injuries are associated with vertically unstable pelvic ring and sacral fractures; however, sciatic nerve palsy after distal femoral traction in a patient who was neurovascularly intact at presentation could not be found in the literature. Several clinical scenarios could have been sole causes or contributing factors to his neurologic complication. These scenarios include but are not limited to: possible hematoma causing mass effect on the nerve, systemic hypotension, under resuscitation, or underlying spinal fractures. Although the patient's neurologic complication cannot definitively be attributed to the use of 18.1 kg of skeletal traction, it is the opinion of the authors that the complication could have been avoided by starting with a lighter amount of traction followed by a gradual increase in traction weight. Serial radiographs could have been used to evaluate the posterior ring reduction to use the lightest weight necessary to maintain adequate reduction. Owing to the complications of this case, the strategy stated above has become our department's protocol for skeletal traction used on vertically unstable fractures. A more detailed patient follow-up would be preferred to help determine whether the complication was due to traction or another factor. The deficit is more likely to be a result of traction as opposed to his underlying spinal fracture because the neurologic injury was unilateral in nature and ipsilateral to the pelvic ring fractures.
1. Tile M: Pelvic ring fractures: Should they be fixed? J Bone Joint Surg 1988;70-B:1.
2. Denis F, Davis S, Comfort T: Sacral fractures: An important problem. Clin Orthop Relat Res 1988;227:67-81.
3. Sulivan C: Fractures of the pelvis. Instructional Course Lectures 1961:92-101.
4. Holm C: Treatment of pelvic fractures and dislocations. Skeletal traction and the dual pelvic traction sling. Clin Orthop Relat Res 1973:97-107.
5. Webb LX, Caldwell K: Disruption of the posterior pelvic ring caused by vertical shear. South Med J 1988;81:1217-1221.
6. Burgess AR, Eastridge BJ, Young JW, et al.: Pelvic ring disruptions: Effective classification system and treatment protocols. J Trauma 1990;30:848-856.
7. Tile M: Acute pelvic fractures: II. Principles of management. J Am Acad Orthop Surg 1996;4:152-161.
8. Tile M: The management of unstable injuries of the pelvic ring. J Bone Joint Surg 1999;81-B:941.
9. Court-Brown C, Heckman J, McQueen M, Ricci W, Tornetta P III: Rockwood and Green's fractures in adults, ed 8. Philadelphia, PA, Lippincott Williams & Wilkins, 2015.
10. Browner B, Jupiter J, Krettek C, Anderson P: Pelvic Ring injuries: Percutaneous posterior pelvic fixation, in: Skeletal Trauma: Basic Science Management, and Reconstruction. ed 5, Philadelphia, PA: Elsevier Saunders, 2015, pp 1021-1105.
11. Azar F, Beaty J, Canale ST: Campbell's Operative Orthopaedics, ed 13, Philadelphia, PA, Elsevier, 2017.