Treatment of subtrochanteric femur fractures can be difficult owing to high risk of complications. No cases of sciatic nerve palsy after hematoma following open reduction and intramedullary nailing of a subtrochanteric femur fracture have been reported. We describe a 28-yearold man who presented with a subtrochanteric fracture in the left femur after a motor-vehicle collision, in whom open reduction and intramedullary nailing led to an immediate postoperative hematoma and sciatic nerve palsy. Prompt diagnosis and early wound exploration resulted in complete resolution of the palsy at 1 month postoperatively. Our findings reinforce the importance of prompt diagnosis and treatment in limiting long-term complications for patients who develop postoperative sciatic nerve palsy associated with hematoma after undergoing operative treatment of subtrochanteric femur fractures

Pedri, Tony G

Treme, Gehron P

English

University of New Mexico

148Case Reports
Abstract
Treatment of subtrochanteric femur fractures can be 
difficult owing to high risk of complications. No cases 
of sciatic nerve palsy after hematoma following open 
reduction and intramedullary nailing of a subtrochanteric 
femur fracture have been reported. We describe a 28-year-
old man who presented with a subtrochanteric fracture 
in the left femur after a motor-vehicle collision, in whom 
open reduction and intramedullary nailing led to an 
immediate postoperative hematoma and sciatic nerve palsy. 
Prompt diagnosis and early wound exploration resulted in 
complete resolution of the palsy at 1 month postoperatively. 
Our findings reinforce the importance of prompt diagnosis 
and treatment in limiting long-term complications for 
patients who develop postoperative sciatic nerve palsy 
associated with hematoma after undergoing operative 
treatment of subtrochanteric femur fractures. 
Introduction 
Subtrochanteric fractures of the femur occur at the 
proximal aspect of the bone, between the lesser 
trochanter to 5 cm distally, with possible proximal or 
distal extension.1,2 The mechanism of injury, location, 
and unopposed muscle forces can make closed 
reduction difficult. Often, open reduction is performed, 
and complications can include increased blood loss, 
malreduction, and loss of fixation.1,2 A fracture table is 
often required for fracture fixation, with risks such as 
pudendal nerve injuries related to traction and sciatic 
nerve injuries of the uninjured side owing to positioning.3  
Sciatic nerve injury after fixation of femur fractures is 
rare, with only a few reported cases. Lhowe and Hansen4 
reported a single case of injury to the sciatic nerve after 
intramedullary nailing for treating a femoral shaft fracture. 
Britton and Dunkerley5 noted sciatic nerve palsy after 
entrapment of the nerve during closed reduction. Sciatic 
nerve injuries have been associated with traction during 
hip arthroscopy.6 Sciatic nerve palsy with postoperative 
hematoma has been described after total hip arthroplasty.7 
No study has reported sciatic nerve palsy in relation to 
postoperative hematoma resulting from open reduction.
We describe a transient sciatic nerve palsy in the 
immediate postoperative period owing to postoperative 
hematoma after open reduction and intramedullary nailing 
for treating a subtrochanteric femur fracture. The patient 
was informed that the data concerning the case would be 
submitted for publication, and he provided verbal consent. 
Case Report 
A 28-year-old man presented to the emergency department 
as the restrained passenger in a motor-vehicle collision. 
He had multiple facial fractures and a closed left 
subtrochanteric femur fracture, classified in the AO/OTA8 
system as type 32-C1.1 (Figures 1A and 1B). On initial and 
secondary examinations, his left ankle could dorsiflex and 
plantarflex and his toe could flex and extend. Sensation to 
light touch was noted along the medial, lateral, dorsum, 
plantar, and first web space of the left foot, indicating intact 
function of the sciatic nerve. A proximal tibia traction pin 
was placed and approximately 6.75 kg (15 lb) of skeletal 
traction was initiated. The patient was admitted to the 
trauma surgical service for further resuscitation.  
Sciatic Nerve Palsy After Operative Treatment of 
Subtrochanteric Femur Fracture Resulting from 
Postoperative Hematoma: A Case Report
Tony G. Pedri, MD; Gehron P. Treme, MD
Department of Orthopaedics & Rehabilitation, The University of New Mexico Health Sciences Center, 
Albuquerque, New Mexico
Figure 1. Preoperative radiographs of the left femur, revealing a closed 
subtrochanteric fracture. A) Anterior-posterior view. B) Lateral view. 
A B
149 The University of New Mexico Orthopaedics Research Journal • Volume 6, 2017
On hospital day 1, the patient was taken for operative 
treatment under general anesthesia. He was positioned on 
a fracture table with a well padded peroneal and underwent 
open reduction and intramedullary nailing of the fracture 
with antegrade greater trochanteric entry nail 
(Figures 2A and 2B). Open reduction was achieved by 
direct manipulation and clamping of the fracture, using 
a direct lateral approach. Meticulous hemostasis was 
obtained with compression and electrocautery. Before 
closing the wound, no active bleeding was noted. Closure 
included the fascia of the iliotibial band, subcutaneous 
tissue, and skin. The operating time was 3 hours and 38 
minutes, with 680 cc of estimated blood loss. Preoperative 
and immediate postoperative hematocrit volumes were 
40% and 18%, respectively. The patient received 2 units 
of packed red blood cells postoperatively, and results of 
a second assessment for hematocrit volume was noted at 
29%. 
At 12 hours postoperatively, the patient described a 
moderate increase in pain, fullness in his thigh at the site of 
the incision, and paresthesias in his foot. This progressed to 
a loss of sensation at the dorsum and plantar aspect of the 
left foot, with complete inability to dorsiflex or plantarflex 
the ankle or move the great toe. The patient rated his pain 
at 7 out of 10 on the visual analog scale. He described this 
pain level similar to that of preoperative time, with no 
notable increase.
Owing to the persistence of pain and loss of sensation 
in the patient, the decision was made to return him to the 
operating room immediately for exploration of the wound.  
He returned to the operating room approximately 13 hours 
after completion of the initial procedure. He was placed 
under general anesthesia. Intraoperatively, the previous 
incision was reopened without any extension of exposure. 
A large hematoma (100 cc) was noted and evacuated. The 
visualized musculature was well perfused and contractile. 
No abnormal active bleeding was noted. After irrigation, 
the wound was packed using damp gauze dressings.
On postoperative day 1, the patient had no sensation 
or motor function below the left knee in a sciatic nerve 
distribution. He could flex and extend the knee with some 
pain limitations. The pain level was described similarly 
as that experienced throughout his presentation. He was 
placed in an ankle-foot orthosis and observed for return 
of nerve function. At 5 days postoperatively, motor and 
sensory function returned throughout the lower extremity, 
with only subtle decreases in strength and sensation 
compared with the uninjured side. At 1-month follow-up, 
the patient was noted to have complete resolution of the 
sciatic nerve palsy. At 8-week follow-up, the patient had 
discontinued using his ankle foot orthosis and showed no 
residual neurological symptoms to the left lower extremity 
(Figures 3A and 3B). He was subsequently lost to follow-up, 
and efforts to contact the patient for a 6-month visit were 
unsuccessful.
 
Discussion
Subtrochanteric femur fractures are frequently the result 
of a high-energy mechanism. Assessment of the initial 
injury, definitive fixation, and postoperative treatment 
course provide unique challenges for orthopaedic surgeons, 
with numerous reported complications.1-3 Although sciatic 
nerve palsy is a well-documented complication after total 
hip arthroplasty and hip arthroscopy, it is a rare occurence 
after operative treatment of subtrochanteric femur 
fractures.6,7,9 Our patient developed sciatic nerve palsy after 
such treatment, which resolved after evacuation of a large 
hematoma.  
Femur-shaft fractures can be associated with acute 
compartment syndrome and sciatic nerve injuries. 
However, sciatic nerve injuries are typically acute and 
unassociated with fixation procedures.10 In the current 
case, the presence of compartment syndrome in the patient 
was felt to be unlikely owing to his moderate pain level 
that did not increase, initial presentation of neurological 
symptoms rather than pain, and intraoperative finding of a 
Figure 2. Intraoperative radiographs of the left femur, showing 
placement of the intramedullary nail at the greater-trochanteric entry 
site. A) Anteroposterior view. B) Lateral view. 
A B
Figure 3. Postoperative radiographs of the left femur at 8-week 
follow-up. A) Anteroposterior view. B) Lateral view.
BA
150Case Reports
large hematoma. Furthermore, we attribute the successful 
treatment of the palsy to an early diagnosis and evacuation 
of the hematoma (within 6 hours of onset of symptoms). 
This notion is consistent with the findings of a similar 
study by Butt et al7 on six patients who underwent total hip 
arthroplasty, in which early diagnosis and evacuation of the 
hematoma in three patients resulted in complete resolution 
of symptoms. Sciatic palsy in the other three patients was 
described as delayed diagnosis, and none had complete 
resolution of symptoms at 4 years postoperatively. 
Sciatic nerve palsy, regardless of the cause, can be a 
devastating injury. In the short term, it can compromise 
a patient’s ability to participate in rehabilitation5,7; in the 
long term, it may severely affect activities of daily living 
and return to previous levels of function.7,9 Our experience 
supports the existing literature on sciatic nerve palsy 
and highlights the importance of prompt recognition 
and treatment in limiting the long-term sequel for 
patients. Thorough documentation of nerve function in 
the perioperative period is crucial to guide appropriate 
treatment. A preexisting palsy or a deficit present 
immediately upon awakening from anesthesia are unlikely 
to benefit from exploration of the wound and may expose 
patients to increased risks associated with further surgical 
procedures. Conversely, progressive neurologic deficits 
require consideration for urgent surgical decompression to 
ensure the best possible outcome.
Funding 
The authors received no financial support for the research, 
authorship, and publication of this article. 
Conflict	of	Interest	
The authors report no conflicts of interest.  
References
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2. Lundy DW. Subtrochanteric femoral fractures. J Am 
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3. Flierl MA, Stahel PF, Hak DJ, Morgan SJ, Smith WR. 
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Sciatic Nerve Palsy After Operative Treatment of Subtrochanteric Femur Fracture Resulting from Postoperative Hematoma: A Case Report

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Sciatic Nerve Palsy After Operative Treatment of Subtrochanteric Femur Fracture Resulting from Postoperative Hematoma: A Case Report

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