The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 93, Issue 19

Case Reports | October 05, 2011

Deep Peroneal Nerve Entrapment by a Spiral Fibular Fracture: A Case Report

Hwee Weng Hey, MBBS, MRCS(IRE); Ter Chyan Tan, MBBCh, BAO, MMED, MRCS(EDIN), FAMS; Amitabha Lahiri, MBBS, FRCS(EDIN), FAMS; Einar P. Wilder-Smith, MBBS, MD, DTM&H, FAMS; V. Prem Kumar, MBBS, FRCS(EDIN), FRCS(GLAS), FAMS; Fareed Husain Kagda, MBBS, FRCS(GLAS), FRCS(EDIN), FAMS; Aymeric Yu Tang Lim, MBBS, FRCS(GLAS), FAMS

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Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

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1Department of Orthopaedic Surgery (H.W.H., V.P.K., and F.H.K.), Department of Hand and Reconstruction Microsurgery (T.C.T., A.L., and A.Y.T.L.), and Department of Medicine (E.P.W.-S.), National University Hospital, 5 Lower Kent Ridge Road, Singapore 119074, Singapore. E-mail address for H.W. Hey: heysadvg@singnet.com.sg

Investigation performed at National University Hospital, Singapore

J Bone Joint Surg Am, 2011 Oct 05;93(19):e113 1-5. doi: 10.2106/JBJS.J.00842

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Abstract

Update

This article was updated on January 4, 2012, to change the authors' names FROM Hwee Weng Dennis Hey, Ter Chyan Tan, Amitabha Lahiri, Einar P. Wilder-Smith, Prem V. Kumar, Fareed Husain Yusuf Kagda, and Yu Tang Aymeric Lim TO Hwee Weng Hey, Ter Chyan Tan, Amitabha Lahiri, Einar P. Wilder-Smith, V. Prem Kumar, Fareed Husain Kagda, and Aymeric Yu Tang Lim.

An erratum has been published: J Bone Joint Surg Am 2012;94(3):e21.

Figures in this Article

Introduction

Introduction | Case Report | Discussion | Acknowledgements | References

Nerves adjacent to bones are prone to injury caused by fractures and fracture fixation. Nowhere is this more true than in the proximal fibular region, where the common peroneal nerve winds around the fibular neck. To our knowledge, despite the close proximity of the common peroneal nerve to the neck of the fibula, no instances of common or deep peroneal nerve palsy caused by indirect trauma have been reported in the literature. We describe a rare case of nerve entrapment associated with a spiral fracture of the proximal part of the fibula that resolved after neurolysis. The patient's family was informed that data concerning the case would be submitted for publication, and they provided their consent.

Case Report

Introduction | Case Report | Discussion | Acknowledgements | References

A twelve-year-old boy sustained a closed spiral fracture of the proximal part of the fibula and the distal part of the tibial shaft (Fig. 1-A) during a tackle in a rugby game. Preoperative examination demonstrated a deficit of great-toe extension and ankle dorsiflexion, but the patient was able to flex all of the toes. There was no vascular injury. He underwent intramedullary nailing with two flexible nails on the day of hospital admission (Fig. 1-B). The entry points were distal to the proximal tibial physis, and the nails were passed manually in an antegrade fashion. Postoperatively, loose bulky dressings and an above-the-knee splint were applied.

Fig. 1-A Fig. 1-B

Fig. 1-A Anteroposterior and lateral radiographs demonstrate spiral fractures of the proximal part of the fibula and the distal part of the tibia before fixation. Fig. 1-B Anteroposterior and lateral radiographs demonstrate spiral fractures of the proximal part of the fibula and the distal part of the tibia after intramedullary nail fixation.

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On the first day after fracture fixation, the patient developed a compartment syndrome of the leg and underwent emergency fasciotomy of all four compartments with two 20-cm incisions (anterolateral and posteromedial). Intraoperatively, a vacuum-assisted wound closure dressing was applied over the fasciotomy wounds. After two weeks, all of the wounds were closed primarily. On examination three months following the fasciotomy wound closures, there was gradual improvement in ankle dorsiflexion and extension of all lesser toes, to a power of grade 4/5. The patient remained unable to extend the great toe, there was no extensor digitorum brevis muscle function, and the first web space had no sensation.

A nerve conduction study confirmed a left proximal deep peroneal neuropathy with low-amplitude motor conduction to the extensor digitorum brevis muscle and the tibialis anterior muscle.

High-definition ultrasound imaging to localize the lesion of the peroneal nerve showed a 3 × 5-cm irregularly shaped hypoechoic area surrounding the proximal aspect of the deep peroneal nerve with loss of hyperechoic epineural signal situated perpendicularly at the fracture site (Fig. 2-A).

Fig. 2-A Fig. 2-B

Fig. 2-A High-definition sagittal plane view ultrasound of the deep peroneal nerve before neurolysis. Fig. 2-B High-definition coronal plane view ultrasound of the deep peroneal nerve after neurolysis.

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Operative Findings

With no recovery of the deep peroneal nerve distal to the branch to the tibialis anterior and extensor digitorum longus muscles, the patient underwent nerve exploration. A curved incision was made over the lateral aspect of the knee. Muscles in the anterior and lateral compartments appeared healthy. The common peroneal nerve was identified proximal to the neck of the fibula and was followed distally deep to the peroneus longus tendon of origin. The deep peroneal nerve was released from within scar tissue, just after it gave off its branches to the tibialis anterior and the extensor digitorum longus muscles; stimulation of these branches demonstrated good muscle contractions. At this level, the nerve was tented by a spike of bone at the proximal end of the fibular fracture with surrounding scar tissue (Figs. 3-A and 3-B). The deep peroneal nerve and the branch to the extensor hallucis longus muscle were released, as was the sensory continuation of the deep peroneal nerve. The bone spike was excised, and the tension on the nerve was relieved.

Fig. 3-A Fig. 3-B

Fig. 3-A Intraoperative photograph of the peroneal nerve and its branches. Fig. 3-B Schematic drawing of the peroneal nerve and its branches.

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Immediately postoperatively, the patient exhibited a descending Tinel-Hoffmann sign along the course of the deep peroneal nerve. This was followed by recovery of first-web-space sensation and great-toe extension, which was grade 4/5 at one month postoperatively. Two months later, full recovery of motor function and sensation, including the extensor digitorum brevis muscle, was observed. High-definition ultrasound imaging six months after surgery showed no hypoechoic area surrounding the proximal aspect of the deep peroneal nerve as was present prior to the neurolysis (Fig. 2-B).

Discussion

Introduction | Case Report | Discussion | Acknowledgements | References

Nerve entrapment following fractures is more commonly recognized in the upper extremities than in the lower extremities¹. Radial nerve entrapment in spiral fractures of the shaft of the humerus was described by Holstein and Lewis in 1963². Fracture entrapment of the radial nerve is attributed to the nerve's relatively fixed course around the humerus, which makes it prone to injury from a proximally displaced and laterally angulated distal osseous spike^3,4.

In a similar manner, the common peroneal nerve is potentially vulnerable to damage when an individual sustains injuries to the head and neck of the fibula^5,6. However, to our knowledge, spiral fractures of the proximal part of the fibula with palsy of the deep peroneal nerve have not been documented in the literature. Damage to the common peroneal nerve has been documented in relation to intramedullary nailing of tibial and fibular fractures⁷ as well as in relation to surgical approaches to the proximal third of the fibula⁸. Open wounds near the fibular neck have also been associated with common peroneal nerve injury.

The common peroneal nerve winds around the fibular neck subcutaneously from posterior to lateral (Figs. 3-A and 3-B). Thereafter, it passes into an unyielding musculoaponeurotic arch deep to the peroneus longus muscle, where it divides into the superficial and deep branches. The deep branch exits anteriorly through the anterior intermuscular septum into the anterior compartment^9,10. This relatively immobile course of the nerve and its terminal branches renders it vulnerable to injury in fractures of the proximal part of the fibula. In our patient, the fracture also resulted in proximal displacement of the distal fragment with a prominent osseous spike laterally.

The muscles supplied by the deep peroneal nerve are, in sequence, the tibialis anterior, the extensor digitorum longus, the extensor hallucis longus, and the extensor digitorum brevis^8,9,11. The nerve terminates as a sensory branch supplying the dorsal aspect of the first web space of the foot. Since the deep peroneal nerve travels deep to the peroneus longus muscle and gives off multiple nerve branches to supply the adjacent muscles mentioned above, it is difficult to define an intermuscular plane during surgery, and the nerve should be approached with caution. The branch to the extensor hallucis longus muscle, in particular, runs a long course in close proximity to the fibula for up to 10 cm from a level below the neck of the fibula before entering the muscle, and it is therefore prone to injury during dissection⁸. With blunt dissection, we were able to correctly identify each of the branches and thus avoid additional nerve injury. Once the entrapped nerve was released, nerve recovery was rapid, as demonstrated by the presence of a descending Tinel-Hoffmann sign immediately postoperatively and subsequent substantial motor and sensory recovery at one month as well as complete recovery by three months postoperatively.

Compartment syndrome was not the cause of the nerve injury in this case, as the deficit of great-toe extension was noted preoperatively, and the anterior and lateral compartment muscles appeared healthy at the time of neurolysis.

This case illustrates two important learning points. A spiral fracture of the proximal part of the fibula can be associated with injury to the relatively immobile common peroneal nerve and its branches, especially if the distal fragment is displaced proximally and has a prominent osseous spike laterally. Additionally, an abrupt stop in the expected sequence of nerve recovery after a closed fracture suggests a lesion of the nerve and is an indication for surgical exploration.

Acknowledgements

Introduction | Case Report | Discussion | Acknowledgements | References

Note: The authors thank Felix Alexandre Rene Lim for his contributions to this article, Aravind Kannan for the high-definition ultrasonographic pictures, and Lee Man Hang for preparation of the figures.

References

Introduction | Case Report | Discussion | Acknowledgements | References

Mino DE; Hughes EC Jr. Bony entrapment of the superficial peroneal nerve. Clin Orthop Relat Res. 1984;185:203-6.[PubMed]

Holstein A; Lewis GM. Fractures of the humerus with radial-nerve paralysis. J Bone Joint Surg Am. 1963;45:1382-8.[PubMed]

Ekholm R; Ponzer S; Törnkvist H; Adami J; Tidermark J. The Holstein-Lewis humeral shaft fracture: aspects of radial nerve injury, primary treatment, and outcome. J Orthop Trauma. 2008;22:693-7.[PubMed][CrossRef]

Shao YC; Harwood P; Grotz MR; Limb D; Giannoudis PV. Radial nerve palsy associated with fractures of the shaft of the humerus: a systematic review. J Bone Joint Surg Br. 2005;87:1647-52.[PubMed][CrossRef]

Bottomley N; Williams A; Birch R; Noorani A; Lewis A; Lavelle J. Displacement of the common peroneal nerve in posterolateral corner injuries of the knee. J Bone Joint Surg Br. 2005;87:1225-6.[PubMed][CrossRef]

Al-Kashmiri A; Delaney JS. Case report: fatigue fracture of the proximal fibula with secondary common peroneal nerve injury. Clin Orthop Relat Res. 2007;463:225-8.[PubMed]

Robinson CM; O'Donnell J; Will E; Keating JF. Dropped hallux after the intramedullary nailing of tibial fractures. J Bone Joint Surg Br. 1999;81:481-4.[PubMed][CrossRef]

Satku K; Wee JT; Kumar VP; Ong B; Pho RW. The dropped big toe. Ann Acad Med Singapore. 1992;21:222-5.[PubMed]

Ryan W; Mahony N; Delaney M; O'Brien M; Murray P. Relationship of the common peroneal nerve and its branches to the head and neck of the fibula. Clin Anat. 2003;16:501-5.[PubMed][CrossRef]

Aigner F; Wiedemann D; Longato S; Fritsch H; Stichelberger M; Piza-Katzer H. [Anatomical considerations on treatment strategies for compression syndromes of the fibular nerve in the proximal leg]. Handchir Mikrochir Plast Chir. 2009;41:238-43. German.[PubMed][CrossRef]

Aigner F; Longato S; Gardetto A; Deibl M; Fritsch H; Piza-Katzer H. Anatomic survey of the common fibular nerve and its branching pattern with regard to the intermuscular septa of the leg. Clin Anat. 2004;17:503-12.[PubMed][CrossRef]

Topics

fibular fractures ; peroneal nerve entrapment ; fracture, spiral

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Hwee Weng Hey, Ter Chyan Tan, Amitabha Lahiri, Einar P. Wilder-Smith, V. Prem Kumar, Fareed Husain Kagda, Aymeric Yu Tang Lim; Deep Peroneal Nerve Entrapment by a Spiral Fibular FractureA Case Report. The Journal of Bone & Joint Surgery. 2011 Oct;93(19):e113 1-5.

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