Nerve Injury (II)
45 yr old lady undergoes vaginal hysterectomy. Surgery was performed in the dorsal lithotomy position with candy cane stirrups, and lasted 75 minutes. On post op day 1, the patient describes walking abnormality.
Assessment reveals right foot drop and right lateral leg numbness.
- Candy cane stirrups
- Foot drop
- Incision location and extension
- Surgical dissection
- Retractor placement
- Patient positioning
The patient appears to suffer from a common peroneal nerve injury. Symptoms usually include foot drop due to motor deficit, and sensory loss along the dorsum of the foot, sometimes extending up the lateral aspect of the leg.
The site where the nerve is most vulnerable to injury is at the knee, where the nerve wraps around the head of the fibula. Although subject to stretch injury, the most common mechanism of injury to common peroneal nerve and its branches is direct compression at the lateral aspect of the calf and knee. This could be seen in patients placed in the lithotomy position, where the stirrups used may be inappropriate or lack adequate padding, forcing the bar or supporting structures to place pressure on the head of fibula and thus compress the common peroneal nerve.
- Awareness of the strain placed upon the nerve when deciding upon patient positioning for surgery
- Care to limit external rotation and abduction at hip joint, both of which may risk femoral nerve injury as well.
- Adequate padding along the lateral aspect of the knee and calf when using candy cane or boot stirrups for lithotomy
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