909
CLINICAL NOTE
Femoral, Saphenous Nerve Palsy After Tourniquet Use:
A Case Report
Ira D. Kornbluth, MD, Mitchell K. Freedman, DO, Liane Sher, MD, Robert W. Frederick, MD
ABSTRACT. Kornbluth ID, Freedman MK, Sher L,
Frederick RW. Femoral, saphenous nerve palsy after tourniquet
use: a case report. Arch Phys Med Rehabil 2003;84:909-11.
Persistent motor and sensory abnormalities after surgery
may affect the rehabilitation process. Patients with continued
weakness may be perceived as lacking motivation by health
care providers. However, there may be an underlying patho-
physiologic abnormality preventing patients from progressing
through their rehabilitation programs. We report a case of a
20-year-old man who underwent surgical repair of multiple
knee structures with the use of a pneumatic tourniquet. Several
weeks after surgery, electromyographic evaluation was done
because he was having difficulty in his rehabilitation because
of persistent weakness. An electromyography and nerve con-
duction study (NCS) revealed femoral and saphenous nerve
palsies. Our report is the first on tourniquet-induced saphenous
nerve injury as well as on abnormal femoral NCSs caused by
tourniquet use. A review of the literature indicates that tourni-
quet-induced nerve palsies are not a rare event. Further eval-
uation should be considered if patients who are having persis-
tent weakness or sensory findings after surgery have used a
tourniquet.
Key Words: Case report; Electromyography; Femoral
nerve; Rehabilitation; Saphenous vein; Tourniquets.
2003 by the American Congress of Rehabilitation Medi-
cine and the American Academy of Physical Medicine and
Rehabilitation
HE PNEUMATIC TOURNIQUET is a very useful instru-
T ment in limb surgeries because it helps control blood
pressure and the amount of blood in the surgical field. For the
most part, tourniquet use is effective and safe. However, a
review of the literature reveals that tourniquets can produce a
wide array of complications,1,2 including nerve palsies.
This report describes the case of a patient noted to have
quadriceps weakness and diminished sensation in the shin after
the use of a pneumatic tourniquet to perform arthroscopic
repair of an internal derangement in a knee. He was found to
have damage to the femoral and saphenous nerves. Although
there are electromyography studies revealing femoral nerve
lesions after tourniquet use, there are few case reports of
femoral nerve lesions and none of saphenous nerve injury after
use of a tourniquet for knee surgery.
From the Rothman Institute (Kornbluth, Freedman, Frederick), the Magee Reha-
bilitation Hospital (Sher); and Departments of Physical Medicine and Rehabilitation
(Kornbluth, Freedman, Sher) and of Orthopedics (Frederick), Thomas Jefferson
University Hospital, Philadelphia, PA.
No commercial party having a direct financial interest in the results of the research
supporting this article has or will confer a benefit upon the author(s) or upon any
organization with which the author(s) is/are associated.
Reprint requests to Ira D. Kornbluth, MD, 834 Chestnut St, Apt 1707, Philadelphia,
PA 19107, e-mail: Doctorira@hotmail.com.
0003-9993/03/8406-7548$30.00/0
doi:10.1016/S0003-9993(02)04809-8
CASE DESCRIPTION
Our patient was a healthy 20-year-old man who suffered a
dislocated knee while wake boarding, an activity in which one
is pulled by a motor boat while kneeling on a board. A closed
reduction of his knee was performed soon after admission to
the emergency room. Magnetic resonance imaging revealed
anterior cruciate ligament (ACL) tear, posterior cruciate liga-
ment tear (PCL), lateral collateral ligament (LCL) tear, partial
tear of the popliteal tendon, partial medial meniscus tear, and
disruption of the iliotibial band and posterolateral capsule.
There was no evidence of numbness or weakness after the knee
injury and before surgical repair. Surgery was delayed 3 weeks
to allow swelling to decrease. Arthroscopic PCL reconstruction
with Achilles tendon allograft, open exploration of posterolat-
eral corner with Achilles tendon allograft reconstruction of the
LCL and popliteus tendon, and open repair of the peripheral
lateral meniscus tear and capsular disruption were performed.
A pneumatic tourniquet was inflated to 300mmHg at the
onset of this procedure. It was deflated 32 minutes thereafter
because of cuff leak. It was reinflated to 300mmHg 3 minutes
later and then deflated after 80 minutes as per the surgeons
request. The cuff was deflated for 53 minutes and then rein-
flated to 300mmHg. The cuff was left inflated for 103 minutes
before being deflated again. After 21 minutes, the cuff was
inflated for 61 minutes. The cuff was deflated a final time just
before completion of the surgery. In total, the cuff was inflated
to a pressure of 300mmHg for about 280 minutes.
The patient was discharged home on crutches with non
weight-bearing status 3 days after surgery. He was seen in
follow-up 5 days after discharge. At that time, it was noted that
the patient had decreased sensation in the saphenous nerve
distribution. No particular weakness was noted. He was non
weight bearing for approximately 8 weeks.
At 18 weeks after the operation, electrodiagnostic studies
were ordered because of persistent quadriceps weakness and a
sensation of numbness along the medial thigh extending below
the knee. The latency for the right femoral nerve conduction
was 6.4ms, and the amplitude was 9V. Left femoral nerve
conduction revealed a latency of 13.7ms and an amplitude of
1V. Right saphenous nerve latency was 3.4ms and amplitude
was 3V. Nerve conduction was absent for the left saphenous
nerve. Conductions of the left peroneal, tibial, and sural nerves
were in the normal range (table 1).
Needle electromyography of the left vastus medialis re-
vealed motor unit potentials of normal amplitude, duration, and
phasicity; increased insertional activity, 2 fibrillations, 2
positive sharp waves, and reduced recruitment was noted.
Needle electromyography of the left L5 paraspinals, left medial
gastrocnemius, left anterior tibialis, and left adductor magnus
did not reveal any abnormalities in recruitment, configuration,
insertional activity, or phasicity. Electromyographic findings
were consistent with axonal lesions of the femoral and saphe-
nous nerves.
The patient underwent ACL repair 4 weeks after the elec-
tromyography was performed. He was seen in follow-up 10
weeks after ACL repair, and quadriceps atrophy and weakness
Arch Phys Med Rehabil Vol 84, June 2003
910 FEMORAL, SAPHENOUS NERVE PALSY FROM A TOURNIQUET, Kornbluth
Table 1: Nerve Conduction Study Performed 18 Weeks After Tourniquet Use for Arthroscopic Repair of a Dislocated Knee
Latency Distance
(m/s) (mm)
MNC data
R femoral 6.4
L femoral 13.7
L peroneal
Ankle-EDB 5.0 330
Below kneeabove knee 12.1
L tibial
Ankle-AHB 4.6 385
Knee-ankle 12.8
SNC data
R saphenous 3.4 140
L saphenous NR 140
L sural 3.7 140
Abbreviations: MNC, motor nerve conduction; R, right; L, left; EDB, extensor digitorum brevis; AHB, abductor hallicus brevis; SNC, sensory
nerve conduction; NR, not recorded.
were still noted. One year later, he was seen in follow-up. He
had no pain. There was no subjective weakness or numbness.
The examination revealed mild hypesthesia to pinprick above
the left medial maleolus and normal strength except for 4/5
strength in the quadriceps.
DISCUSSION
Femoral nerve palsies can occur as a complication of surgery
for various reasons. Reported causes include fluid extravasa-
tion after use of an infusion pump,3 retroperitoneal hematoma,4
and the use of self-retaining retractors.4 Dobner and Nitz5
reported femoral nerve palsy as a result of tourniquet use in
several patients after arthroscopic knee surgery. Although 10 of
24 patients in whom a tourniquet was used to perform arthro-
scopic knee surgery exhibited femoral nerve denervation by
electromyography, none of these patients was found to have
abnormal nerve conduction studies (NCSs). Tourniquet pres-
sures ranged from 300 to 450mmHg with a mean of 393mmHg
for those with a femoral nerve palsy and a mean of 390mmHg
in patients without evidence of femoral nerve damage. Tour-
niquet time also did not vary significantly: the tourniquet group
had a mean application time of 42 minutes, and the control
group had a mean application time of 50 minutes.
Unlike the patients in Dobners study,5 our patient did in fact
have abnormal NCSs. The amplitude discrepancy between the
unaffected side (9V) and the affected side (1V) indicates a
profound axonal lesion. Reid et al6 showed that the pressure
needed to maintain a bloodless field was 255mmHg for upper-
extremity surgery and 305mmHg for lower-extremity surgery.
Because tourniquet pressures were well within the accepted
range, the duration of tourniquet use appears to be the predom-
inant causative factor for our patient. Saunders et al7 correlated
the presence of electromyographic abnormalities to the dura-
tion of pneumatic tourniquet use in patients who underwent
knee arthrotomy. At 3 to 4 weeks postoperation, 11 of 13
(85%) patients in whom a tourniquet was used for more than an
hour had a nerve palsy by electromyography versus 2 of 9
(22%) patients with tourniquet use times under 15 minutes. The
most commonly affected muscle in Saunders study7 was the
quadriceps. Total tourniquet time for our patient was 280
minutes, with the longest consecutive period being 103 min-
utes. Rorabeck and Kennedys experiments8 on dogs led them
to propose that tourniquets should not be used beyond 75
minutes. They also suggested that once a tourniquet is deflated,
Arch Phys Med Rehabil Vol 84, June 2003
Conduction Velocity Amplitude Duration Stimulation
(m/s) (V) (m/s) (mA)
9 11.5 37
1 8.1 100
46.5 4 7.8 84
3 8.8 100
47.0 9 6.1 48
7 6.6 100
3 1.3
NR NR NR
17 4.0
it should not be reinflated.8 Fox et al,9 however, believe that 2
hours of consecutive tourniquet time is acceptable; they advo-
cate releasing the tourniquet for 10 minutes every hour if the
procedure will exceed 2 hours. In retrospect, it appears that our
patient likely experienced a femoral nerve palsy because of
prolonged use of the tourniquet.
The electrodiagnostic findings appear to be because of the
peripheral nerve lesion and not because of the effects of de-
conditioning and muscle atrophy. Hoyer et al10 noted 14.1%
higher amplitudes, 6.5% longer duration, and a 13.2% increase
in polyphasicity when comparing an immobilized, atrophic
vastus medialis with the nonimmobilized vastus medialis on
the contralateral side. These findings were not present in our
patient. However, even if they were present, these findings can
also be seen in subacute denervation. In our patient, denerva-
tion potentials were limited to the quadriceps, and conduction
abnormalities were limited to the femoral and saphenous
nerves. Thus, the electrodiagnostic findings in our patient can-
not be explained solely by the effects of immobility. Moreover,
if electrodiagnostic findings were because of the effects of
deconditioning and muscle atrophy, one would expect that
abnormalities would be found diffusely in the left lower limb,
and not limited to the femoral and saphenous nerve distribu-
tions.
A survey of surgeons in the Australian Orthopaedic Associ-
ation11 reported the incidence of nerve palsy as 1 in 5000 after
upper-extremity tourniquet use and 1 in 13000 after lower-
extremity tourniquet use. Interpretation of this survey should
take into account that data were voluntarily provided and that
electrodiagnostic testing is not routinely done in the postoper-
ative period. In this survey, there was mention of a single case
of a femoral and sciatic nerve palsy resulting from a tourniquet
that was inadvertently left in place for a 412-hour period.
CONCLUSION
In general, femoral nerve injuries have a good prognosis and
tend to recover over a period of days to a few months. Few
actual persistent palsies are reported in the literature. This
problem may be underdiagnosed because of weakness from the
procedure in general as well as rapid recovery by the nerve.
Based on our literature review, nerve damage as a result of
tourniquet use is not uncommon. It may be an underappreciated
occurrence in terms of its frequency and its impact on the
rehabilitation process.12,13 Patients who do not progress as
 FEMORAL, SAPHENOUS NERVE PALSY FROM A TOURNIQUET, Kornbluth
rapidly as they should in the rehabilitation process are often
perceived as lacking motivation or commitment. However,
delayed recovery may be the result of a slowly resolving axonal
compression syndrome caused by the pneumatic tourniquet.
Physicians should consider a work-up for peripheral nerve
palsy after tourniquet use if any of the signs and symptoms of
femoral nerve damagefor example, atrophy, altered sensa-
tion, and altered strengthare present.
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Arch Phys Med Rehabil Vol 84, June 2003