The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 86, Issue 8

Scientific Articles | August 01, 2004

Anatomic Location of the Peroneal Nerve at the Level of the Proximal Aspect of the Tibia: Gerdy's Safe Zone

Ivan F. Rubel, MD¹; Itchak Schwarzbard, MD¹; Anthony Leonard, RN¹; Donna Cece, PA¹

¹ Department of Orthopaedics, Kings County Hospital Center, Room C-3125, 451 Clarkson Avenue, Brooklyn, NY 11203. E-mail address for I.F. Rubel: ivanrubel@yahoo.com

View Disclosures and Other Information

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Investigation performed at the Department of Orthopaedics, Kings County Hospital Center, Brooklyn, New York

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2004 Aug 01;86(8):1625-1628

5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case

Article

Comments (0)

text A A A

Abstract

Background: Injury to the peroneal nerve is one of the most serious complications in orthopaedic surgery. Because percutaneous procedures at the level of the proximal aspect of the tibia are becoming increasingly popular, it is critical to have a thorough knowledge of the trajectory of the peroneal nerve and its main branches at the level of the proximal aspect of the tibia. This anatomic study was conducted in an attempt to (1) define the anatomy of the common peroneal nerve and its branches in a three-dimensional fashion and (2) identify an anatomic landmark on the surface to help define a safe area that is void of the main nerve and its branches.

Methods: Thirty-one adult unembalmed cadaveric legs were dissected. The peroneal nerve was identified at the level of the posterior aspect of the lateral femoral condyle and was dissected distally to the level of its intramuscular branches. The relationship between the peroneal nerve and Gerdy's tubercle was explored, and the distances from the nerve and its branches to the tubercle were measured and recorded in millimeters. The average distances and standard deviations from Gerdy's tubercle to the neural structures were calculated.

Results: The course of the common peroneal nerve trunk and its anterior recurrent branch defined an arc with a circumference having an average radius of 45 mm. This circumferential trajectory was seen to be centered at the most prominent aspect of Gerdy's tubercle.

Conclusions and Clinical Relevance: The path of the common peroneal nerve and its proximal branch were notable in two regards: their circular nature and their consistent relationship to the most prominent aspect of Gerdy's tubercle. With Gerdy's tubercle used as a landmark, the trajectory of the peroneal nerve can be easily defined at the level of the proximal aspect of the tibia and marked prior to the placement of devices and instrumentation, thereby avoiding damage to the peroneal nerve and its branches.

Figures in this Article

The peroneal nerve provides motor innervation to the muscles in the anterolateral compartment of the leg. Two of its most important functions are dorsiflexion of the ankle and extension of the toes, both of which are key components of a normal gait. Damage to the peroneal nerve can be a devastating complication of surgery at the level of the proximal aspect of the tibia^1,2. The surgical anatomy and relationships of the peroneal nerve have been studied thoroughly^3-7. However, most of those studies have described the nerve and its branches in relation to the head of the fibula in a linear, two-dimensional fashion^6,7, making the spatial relationship of the nerve to the proximal aspect of the tibia difficult to understand. The objectives of our study were (1) to define the anatomy of the peroneal nerve and its branches in a three-dimensional fashion, and (2) to identify an anatomic landmark on the surface of the tibia to help to map the trajectory of the nerve and its branches as they enter the anterior and lateral compartments of the leg.

Materials and Methods

Materials and Methods | Results | Discussion | References

Thirty-one adult unembalmed human cadaveric knees were dissected. A lateral approach to the proximal aspect of the tibia and fibula was performed, and the common peroneal nerve was identified at the level of the posterior aspect of the lateral femoral condyle. The nerve was dissected distally as it came around the neck of the fibula, with care being taken to avoid distorting any of the local anatomy (the fibers of the peroneus longus, the biceps femoris insertion, and the crural fascia) so as to allow for accurate measurements. The superficial branch and deep branch were followed as they entered the anterior and lateral compartments of the leg. The anterior recurrent branch was also dissected and followed as it crossed the anterior compartment perpendicular to the shaft of the tibia. The relationship of the nerve and its branches to the proximal tibial metaphysis was analyzed (Fig. 1). In all specimens, Gerdy's tubercle appeared to be in the center of the nerve's circular trajectory. Three distances were defined and recorded in millimeters with use of precision calipers. Since Gerdy's tubercle is a fairly broad and ill-defined structure, the consistent point of measurement was from its most prominent aspect. Distance I (d I) indicated the distance from the most prominent aspect of Gerdy's tubercle to the common peroneal nerve behind the head of the fibula. Distance II (d II) indicated the distance from the most prominent aspect of Gerdy's tubercle to the starting point of the superficial branch of the common peroneal nerve. Distance III (d III) was the distance from the most prominent aspect of Gerdy's tubercle to the anterior recurrent branch of the nerve (Fig. 2).

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 1: Cadaveric dissection showing the anatomic location of the peroneal nerve at the level of the proximal aspect of the tibia. Note the close relationship of the main trunk of the nerve to the neck of the fibula (black arrow). The distance from the tip of the fibula to the nerve varies as its branches fan over the proximal aspect of the fibula toward the muscles of the anterior compartment of the leg. The anterior recurrent branch (white arrow) is the most proximal of the terminal branches of the superficial peroneal nerve.

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 2: Cadaveric dissection of a fresh tissue specimen showing the circumferential area free of neural structures at the level of the proximal aspect of the tibia. The center of this circumference is located at the Gerdy's tubercle with an average radius (and standard deviation) of 45.32 ± 2.6 mm. d I = distance from the most prominent aspect of Gerdy's tubercle to the common peroneal nerve behind the head of the fibula, d II = distance from the most prominent aspect of Gerdy's tubercle to the starting point of the superficial branch of the common peroneal nerve, and d III = distance from the most prominent aspect of Gerdy's tubercle to the anterior recurrent branch of the nerve.

Results

Materials and Methods | Results | Discussion | References

The trajectory of the common peroneal nerve, the proximal portion of the superficial and deep peroneal nerves, and the anterior recurrent branch were seen to follow an arc with an average radius (and standard deviation) of 45.32 ± 2.6 mm (range, 41 to 49 mm) centered at the most prominent aspect of Gerdy's tubercle. Figures 1 and 2 show how the trajectory of the nerve changes from a more superficial path around the neck of the fibula to a deeper path as it enters the muscles of the anterior compartment of the leg. In addition, the nerve also describes a curve with a posterior concavity in the axial plane as it completes its trajectory through the anterior compartment. This circular trajectory is spatially placed in a plane oblique to both the sagittal and the coronal plane. The distances between the most prominent aspect of Gerdy's tubercle and the common peroneal nerve at the level of the head of the fibula (I), the superficial peroneal nerve starting point (II), and the most distal portion of the anterior recurrent branch of the peroneal nerve (III) were equal (Fig. 2). If the 0° point of a circle is set at the level of the head of the fibula, the common peroneal nerve divides into deep and superficial branches, on the average, at 35° and the tibial crest is located, on the average, at 100°.

Discussion

Materials and Methods | Results | Discussion | References

The fibers of the peroneal nerve arise from the lateral border of the popliteal fossa. As the nerve wraps around the head of the fibula, it consistently divides into three main branches: the anterior recurrent branch, the superficial branch, and the deep peroneal branch^4,6,8. Since damaging the peroneal nerve could have serious functional consequences, the anatomic relationships of the nerve to the proximal aspect of the tibia have been thoroughly studied. However, most of the published anatomic studies have described the location of the peroneal nerve only in a linear fashion, in two dimensions, and in relation to the head of the fibula, which makes the preoperative marking of the trajectory of the peroneal nerve very difficult.

Stitgen et al. described the branching anatomy of the common peroneal nerve as well as a "safe zone" for the percutaneous placement of pins at the level of the proximal aspect of the tibia⁶. Their safe zone is located anterior to the fibula and up to 2 cm from its proximal end, creating an estimated area of 4 cm^2,6. This calculation leaves a substantial area of the proximal aspect of the tibia, i.e., the area proximal to the tip of the fibula and behind the fibular head, out of consideration.

Takeda et al. defined a safe zone to perform percutaneous biopsies at the level of the proximal aspect of the fibula⁷. In their study, the nerve was seen to cross the shaft of the proximal aspect of the fibula at a 23° angle. Their description is valid only for the small portion of the main nerve that crosses the fibular shaft and only if the knee is being considered in the coronal plane⁷.

Identification of safe crossing angles for fine wires is useful to avoid damaging vital structures at a given axial location. However, the three-dimensional integration of the multiple-level coordinates needed to follow the anatomic location of a given nerve makes this method too difficult to be used on a regular basis.

Moskovich performed anatomic dissections in an attempt to map the trajectory of the peroneal nerve³ and concluded that traction pins at the level of the proximal aspect of the tibia should be positioned on the center of the tibia in the coronal plane since the common peroneal nerve and its major branches are predominantly posterior to the proximal aspect of the tibia. In order to obtain these measurements, Moskovich marked the nerve with lead sutures and made radiographs. Interestingly, one illustration from that report shows how the nerve and its anterior recurrent branch describe a circle around Gerdy's tubercle³.

When the position of the peroneal nerve is defined in relation to the most prominent aspect of Gerdy's tubercle, a safe zone at the level of the proximal aspect of the tibia can be easily identified and marked preoperatively (Figs. 3-A and 3-B). The surgeon should mark Gerdy's tubercle and the posterior border of the fibular head and measure the distance between the two. This distance can then be transposed over to the anterior aspect of the leg along the lateral border of the tibial crest. Additional markings can be transposed in between the two initial measurements, and all measurements can then be connected with a surgical marking pen (Figs. 3-A and 3-B). Another possibility would be to tie a large suture around a marking pen at that distance, and, while holding the end of the suture on Gerdy's tubercle, rotate the pen in a circular fashion from the fibular head to the tibial crest. The surgeon needs to keep in mind that the marking only guides where the nerve and its branches could be in an attempt to avoid injuring them while approaching the area.

View Large | Download Slide(.ppt)
Add to My JBJS

Figs. 3-A and 3-B: The Gerdy's safe zone can be marked preoperatively. Note how the marking follows the contour of the surface in a three-dimensional fashion on these lateral (Fig. 3-A) and frontal (Fig. 3-B) photographs.

The path of the peroneal nerve maintains a constant radius around Gerdy's tubercle through an arc of 100°, starting at the fibular head and ending at the tibial crest. It is important to emphasize that the distance of the peroneal nerve from Gerdy's tubercle varies among patients. Rather than proposing a numeric safe zone, we were able to identify and easily mark an anatomic zone. The distance between Gerdy's tubercle and the fibular head determines the radius of this anatomic safe zone. Our investigation and other studies^9-12 have found no other peroneal nerve branches inside this area.

By using Gerdy's tubercle as our main landmark, we were able to map the trajectory of the nerve in three planes: axial, as the nerve progresses from proximal to distal; coronal, as it tracks from the posterior to the anterior part of the leg; and sagittal, as it tracks from lateral to medial and enters the anterior compartment of the leg.

The tibia-fibula-peroneal nerve relationship proposed in this study requires an intact proximal syndesmosis and maintenance of the proximal tibial length. A previous operation, acute fracture with comminution and disruption of the proximal syndesmosis, or developmental abnormalities may alter the otherwise constant position of the nerve behind the fibular head¹³. In these situations, Gerdy's safe zone may also be altered. In addition, since no dissections were performed in cadaveric specimens from children, we cannot recommend the application of our findings in children. Failure to identify Gerdy's tubercle or the posterior aspect of the head of the fibula in cases of extreme obesity or severe soft-tissue swelling may also preclude the use of this method.

References

Materials and Methods | Results | Discussion | References

Kirgis A, Albrecht S. Palsy of the deep peroneal nerve after proximal tibial osteotomy. An anatomical study. J Bone Joint Surg Am.1992;74: 1180-5.741180 1992 [PubMed]

Slawski DP, Schoenecker PL, Rich MM. Peroneal nerve injury as a complication of pediatric tibial osteotomies: a review of 255 osteotomies. J Pediatr Orthop.1994;14: 166-72.14166 1994 [CrossRef]

Moskovich R. Proximal tibial transfixion for skeletal traction. An anatomic study of neurovascular structures. Clin Orthop.1987;214: 264-8.214264 1987 [PubMed]

Rupp RE, Podeszwa D, Ebraheim NA. Danger zones associated with fibular osteotomy. J Orthop Trauma.1994;8: 54-8.854 1994 [CrossRef]

Soejima O, Ogata K, Ishinishi T, Fukahori Y, Miyauchi R. Anatomic considerations of the peroneal nerve for division of the fibula during high tibial osteotomy. Orthop Rev.1994;23: 244-7.23244 1994

Stitgen SH, Cairns ER, Ebraheim NA, Niemann JM, Jackson WT. Anatomic considerations of pin placement in the proximal tibia and its relationship to the peroneal nerve. Clin Orthop.1992;278: 134-7.278134 1992

Takeda A, Tsuchiya H, Mori Y, Tanaka S, Kikuchi S, Tomita K. Anatomical aspects of biopsy of the proximal fibula. Int Orthop.2001;24: 335-7.24335 2001 [PubMed][CrossRef]

Williams PL, editor.Gray's anatomy. The anatomical basis of medicine and surgery. 38th ed. New York: Churchill Livingstone; 1995. 1995

Ihunwo AO, Dimitrov ND. Anatomical basis for pressure on the common peroneal nerve. Cent Afr J Med.1999;45: 77-9.4577 1999

Adkison DP, Bosse MJ, Gaccione DR, Gabriel KR. Anatomical variations in the course of the superficial peroneal nerve. J Bone Joint Surg Am.1991;73: 112-4.73112 1991 [PubMed]

Dellon AL, Ebmer J, Swier P. Anatomic variations related to decompression of the common peroneal nerve at the fibular head. Ann Plast Surg.2002;48: 30-4.4830 2002 [PubMed][CrossRef]

Reimann R. [Accessory peroneal nerves in the human]. Anat Anz.1984;155: 257-67. German.155257 1984 [PubMed]

El-Shazly M, Saleh M. Displacement of the common peroneal nerve associated with upper tibial fracture: implications for fine wire fixation. J Orthop Trauma.2002;16: 204-7.16204 2002 [CrossRef]

Topics

fibula ; neurons ; common peroneal nerve ; tibia ; leg

Username

Password

Access for Patients

Forgot Password?

Have a subscription to the print edition?

Not a Subscriber?

Buy this Article

Get online access for 30 days for $35

New to JBJS?

Subscribe to the online edition for 30 days for $75

Register for a FREE limited account to get full access to all CME activities, to comment on public articles, or to sign up for alerts.

Have a subscription to the print edition?

Current subscribers to The Journal of Bone & Joint Surgery in either the print or quarterly DVD formats receive free online access to JBJS.org.

Activate your online account now

Forgot your password?

Enter your username and email address. We'll send you a reminder to the email address on record.

Username:*

Email Address:*

Forgot your username or need assistance? Please contact customer service at subs@jbjs.org. If your access is provided
by your institution, please contact you librarian or administrator for username and password information. Institutional
administrators, to reset your institution's master username or password, please contact subs@jbjs.org

References

Accreditation Statement

These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.

CME Activities Associated with This Article

Submit a Comment

Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
Comments are moderated and will appear on the site at the discretion of JBJS editorial staff.

* = Required Field

Comment Author(s) * (if multiple authors, separate names by comma)

Example: John Doe

Affiliation & Institution*

Disclosure

Comment Title*

Comment*

Cancel

Print
PDF
Email

Recipient(s) will receive an email with a link (good for 5 days) to 'Anatomic Location of the Peroneal Nerve at the Level of the Proximal Aspect of the Tibia: Gerdy's Safe Zone'.
Your Name:*
Example: John Doe

Email Address:* CC Me:
Enter your valid email address. Example: jdoe@example.com

Recipient's Email Address:*

Separate multiple email address with semi-colons (up to 5).

Subject:* 's The Journal of Bone & Joint Surgery: 'Anatomic Location of the Peroneal Nerve at the Level of the Proximal Aspect of the Tibia: Gerdy's Safe Zone'
Subject for your email.

Message:

(Optional, message will truncate at 1000 characters)

Processing your request... Please Wait...

Copyright © in the material you requested is held by The Journal of Bone & Joint Surgery, Inc. (unless otherwise noted). This email ability is provided as a courtesy, and by using it you agree that that you are requesting the material solely for personal, non-commercial use, and that it is subject to Journal of Bone & Joint Surgery, Inc.'s Terms of Use. The information provided in order to email this topic will not be used to send unsolicited email, nor will it be furnished to third parties. Please refer to The Journal of Bone & Joint Surgery Inc.'s Privacy Policy for further information.

Copyright © The Journal of Bone & Joint Surgery Inc. All rights reserved.
Share
Get Citation

Ivan F. Rubel, Itchak Schwarzbard, Anthony Leonard, Donna Cece; Anatomic Location of the Peroneal Nerve at the Level of the Proximal Aspect of the Tibia: Gerdy's Safe Zone. The Journal of Bone & Joint Surgery. 2004 Aug;86(8):1625-1628.

Download citation file:

RIS (Zotero)

EndNote

BibTex

Medlars

ProCite

RefWorks

Reference Manager

Copyright © The Journal of Bone and Joint Surgery, Inc.
Rights & Permissions
Article Alerts

Processing your request... Please Wait.
Submit a Comment