Date: Thu, 13 Jun 2002 09:34:39 +0600
Subject: Burning pain and hypersensation of the foot
Hello All,
A month ago i posted a case of comminuted femoral fracture which then was nailed. He is my second patient after closed femoral nailing with complaints of hypersensation and burning pain in the foot. Mostly plantar area and lateral side, though dorsal and medial sides are also involved up to the ankle. The first one had been experiencing the same during 2 months then it was momentarily turned off without any external reason. This one also is not responding to NSAIDs and finlepsin. What can cause the disorders and what yet can be administered to relieve symptoms?
THX in advance.
Best regards,
Alexander N. Chelnokov
Ural Scientific Institute of Traumatology and Orthopaedics
str.Bankovsky, 7. Ekaterinburg 620014 Russia
Date: Thu, 13 Jun 2002 07:04:23 -0400
From: J. Tracy Watson
This may represent a traction injury....forceful , prolonged, unpadded, traction with the fracture table....neurontin sometimes works for the dysesthesias......
JTW
Date: Thu, 13 Jun 2002 10:59:53 -0400
From: James Carr
I agree with Tracy. Do you use a traction pin or a boot with the leg in full extension? I routinely use a traction pin inserted in the tibial metaphysis near Gerdy's tubercle. This allows the knee to flex, even with heavy traction, and I think takes stress off the sciatic nerve. The nerve palsy's I have seen have been done with the traction boot with the knee extended. Secondly, we only apply the heavy forces during reduction/wire passage, and release it as soon as possible. This reduces the possibility of pudendal nerve palsy or pressure sores on the perineum. Use Neurontin at 300 tid, increasing to 900 tid over two weeks. Some experience good relief. If no effect by 2700 mg/day, I usually stop, although some of my rehab MD's go even higher.
James B. Carr, MD
Palmetto Health Orthopedics
Date: Sat, 15 Jun 2002 11:38:00 +0600
From: Alexander Chelnokov
Hello JTW
JTW> This may represent a traction injury....forceful , prolonged, unpadded, traction with the fracture table...
Both were done with the distractor. I wouldn't say over-traction was outstanding, especially the mentioned first case was completely routine. And the disorder was started some days later in both cases.
JTW> neurontin sometimes works for the dysesthesias
THX for the advice, will check whther the drug is available on the local market.
Best regards,
Alexander N. Chelnokov
Ural Scientific Institute of Traumatology and Orthopaedics
str.Bankovsky, 7. Ekaterinburg 620014 Russia
Date: Sun, 16 Jun 2002 21:01:35 +0530
From: "Dr.R.SACHIDANANDAN" Dear James,
Could you please give the generic name of Neurontin? What are the side
effects to be looked for? Can this be used for other neuralgias?
Thanks in advance,
Dr.R.Sachidanandan
Date: Mon, 17 Jun 2002 08:58:21 +0600 From: Alexander Chelnokov Hello Dr.R.SACHIDANANDAN, DRS> Could you please give the generic name of Neurontin? What
are the side effects to be looked for? Can this be used for other neuralgias? Best regards,
Alexander N. Chelnokov
Date: Mon, 17 Jun 2002 09:46:07 -0400
From: James Carr
I believe that some of these are subclinical nerve injuries on presentation
that manifest themselves at a later date. The only clues can be vague sensation
of numbness or tingling in the nerve distribution despite a seemingly normal
exam. I have seen a few develop into full blown causalgia. It occurs most
commonly in my practice in the setting of a hip fx-dislocation. Sounds like the
usual fx table problems I see can't be blamed in your case.
Jim Carr
James B. Carr, MD
Date: Mon, 17 Jun 2002 13:28:15 -0600
From: Thomas A. DeCoster
Regarding the case of foot dysesthesia after IM nailing of femur shaft
fracture. A variety of traction injuries to nerves have been reported
after IM nailing including sciatic (tibial and peroneal), femoral and
pudendal. Fracture table and traction of reduction are most often
implicated. Padding, positioning, minimized duration of traction,
avoiding fracture table altogether,... as mentioned on this site help
minimize risk of this complication. Nails that are done early require
less traction. If you wait several days or longer there is shortening at
the fracture which then requires more traction to get reduction and
greater risk of nerve injury. Skeletal traction OUT TO LENGTH from injury
to operation helps. Use the LATERAL radiograph in traction to make sure
you are out to length as the AP appearance can be misleading.
Of course there are etiologies other than nerve stretch or direct pressure
including compartment syndrome, direct nerve injury from extra-medullary
instruments, drill bits, electrocautery near nerves, the traction pin
itself, under reaming and forceful nail insertion...
I can't say that I've seen this problem commonly. At least I haven't
noticed it.
The Journal of the American Academy of Orthopedic Surgeons (JAAOS) June
2002 p 153-156 has a nice summary article on Gabapentin (Neurontin) by Dr.
Rosenquist.
Tom DeCoster
Cochin,INDIA.
Ural Scientific Institute of Traumatology and Orthopaedics
str.Bankovsky, 7. Ekaterinburg 620014 Russia
Palmetto Health Orthopedics