Compartmental anatomy of the superficial fibular nerve with an emphasis on fascial release operations of the leg

A Traumatic Neuroma Formation Following Fasciotomy for the Treatment of Tibialis Anterior Muscle Herniation: A Case Report

Muscle herniation of the lower extremity, such as tibialis anterior muscle herniation (TAMH), is not a rare cause of leg pain in athletes. However, a few studies have reported surgical treatment for TAMH, and the optimal surgical procedure remains controversial. Fasciotomy was reported to be effective for patients with TAMH. However, this procedure would be associated with a risk of intraoperative injury to the superficial peroneal nerve (SPN), although no previous literature has reported this complication. This case report aimed to report a case of bilateral TAMHs in which a traumatic neuroma of the SPN developed after fasciotomy. A 16-year-old baseball player presented with painful swelling lesions of the bilateral lower extremities (1 lesion on the right, 3 lesions on the left) after sports activities. An ultrasonographic evaluation showed swelling lesions of the anterolateral parts of the bilateral lower extremities in the standing position after dashing, while these lesions were not detected in the supine position. A fasciotomy of the crural fascia was performed after conservative treatment failed. Several days after surgery, the patient presented with weakened touch sensation over the dorsal area of the left foot. At the three-month follow-up examination, a swelling lesion with hard elasticity was identified. The palpation of this lesion caused a radiating sensation in the area supplied by the SPN. He was able to return to playing baseball six months after surgery. The patient was asymptomatic without palpation of the traumatic neuroma of the SPN at the latest follow-up examination. In conclusion, the present case report suggests that orthopedic surgeons need to consider the risk of iatrogenic injury to the SPN during fasciotomy for the treatment of TAMHs. However, there may be a risk of injuring the SPN because of the many variants of the course of the SPN within the compartment of the lower extremities.

Relationships of the superficial fibular nerve and sural nerve with respect to the lateral malleolus: implications for ankle surgeons

PURPOSE

Superficial fibular nerve (SFN) and sural nerve are at risk during osteosynthesis of the lateral malleolus. The aim of this anatomical study was to describe the relationships of the superficial fibular and sural nerves with respect to the lateral malleolus.

METHODS

Nine corpses (18 ankles) were dissected, using a direct lateral approach. Measurements were recorded between the fibula and the nerves, and the pattern variations of the SFN were recorded for both right and left side to assess intra-individual variability.

RESULTS

Distance between the tip of the lateral malleolus and the piercing of fascia cruris was 111 ± 26 mm for type 1 pattern, and range was 46-161 mm all types included. 78% (14 SFN) were type 1 pattern, 17% (3 SFN) were type 2 pattern, and 5% (1 SFN) were type 3 pattern. 44% (4 specimen) had a type 1 pattern SFN on one ankle and another pattern on the other ankle. The sural nerve was always observed just posterior to the lateral malleolus.

CONCLUSION

This study demonstrated a great inter-individual variability especially for the SFN, but also an intra-individual variability with frequent different patterns between right and left leg. It is important to know the anatomical variations of the SFN and sural nerve to decrease the risk of intra operative nerve injury during direct lateral approach of lateral malleolus.

The Intraseptal Course of the Superficial Peroneal Nerve: An Anatomic Study

BACKGROUND

Anatomic and clinical studies show many variants of the superficial peroneal nerve (SPN) course and branching within the compartments and at the suprafascial layer. The anatomy of the transition zone from the compartment to the subcutaneous layer has been occasionally described in the literature, mainly in studies reporting the intraseptal SPN variant in 6.6% to 13.6% of patients affected by the SPN entrapment syndrome. Despite the little evidence available, the knowledge of the transition zone is relevant to avoid iatrogenic lesions to the SPN during fasciotomy, open approaches to the leg and ankle, and SPN decompression. Our anatomic study aimed to describe the SPN transition site and to evaluate the occurrence of a peroneal tunnel and of an intraseptal SPN variant.

METHODS

According to the institutional ethics committee requirements, 15 fresh-frozen lower limbs were dissected to study the SPN course and its branching, focusing on the transition site to the suprafascial layer.

RESULTS

The SPN was located in the anterior compartment in 2 cases and in the lateral in 13. An intraseptal tunnel was present in 10 legs (66%), at a mean distance of 10.67 cm from the lateral malleolus. Its mean length was 2.63 cm. The tunnel allowed the passage of the main SPN in 8 cases and of its branches in two. In the remaining 5 legs (33%), the SPN pierced a crural fascia window.

CONCLUSION

In our sample a higher rate than expected of intraseptal SPN variants was found.

CLINICAL RELEVANCE

The knowledge of the anatomy of the SPN course and intraseptal variant is relevant to avoid iatrogenic lesions during operative dissection. Further studies are needed to evaluate the effective prevalence of an intraseptal tunnel, independently from the SPN entrapment syndrome, and how to avoid associated iatrogenic complications.

A simple method of skin mapping for planning the operative approach in peripheral nerve injuries

BACKGROUND

The operative treatment of post-traumatic neuromas includes open exploration, excision of adhesions and/or neurectomy. Apart from the anatomical variations of the peripheral nerves and their branches' routes, nerves may be further deviated from their expected anatomical locations due to scar tissue formation. We describe a simple and reproducible method of preoperative skin marking which aids the development of an accurate surgical exposure for the localisation of a lesion.

METHOD

Skin marking is based on clinical assessment and is performed by the bedside on the day of the operation. It consists of mapping the skin with permanent marker by repeatedly using three symbols, namely √, O or X. These refer respectively to areas of normal sensation, numbness (decreased or no sensation without paraesthesia) and pain/dysaesthesia. Points with a positive Tinel sign were marked with an "X in a square". Fourteen patients, aged 21-55 years old, with post-traumatic neuromas, were marked with the method. A total of 18 neuromas were successfully located in the upper and lower limbs.

RESULTS

In all cases the preoperative skin marking corresponded to the course of the nerve and/or its branches. All patients were improved with a good to excellent clinical outcome.

CONCLUSIONS

Planning the surgical approach according to the skin marking enabled limited operative exposures and corresponded to atypical locations and branching of the peripheral nerves.

Superficial Peroneal Nerve Incarceration in the Fibular Fracture Site of a Pronation External Rotation Type Ankle Fracture

Ankle fractures are common representing up to 10% of all fractures with an incidence that is rising. Both conservative treatment and operative management of ankle fractures can lead to excellent outcomes. Neurovascular injuries are uncommon but can be a source of significant morbidity and associated poor outcome. The superficial peroneal nerve (SPN) in the lateral approach and the sural nerve in the posterolateral approach are at risk of injury. We report an unexpected finding of a superficial peroneal nerve incarcerated in the fibular fracture site of pronation external rotation type/ Weber-C ankle fracture. To the best of our knowledge we believe this to be the first English language report of an incarcerated SPN at a fibular ankle fracture site.

Entrapment of the superficial peroneal nerve: an anatomical insight

Entrapment of the superficial peroneal nerve is an uncommon neuropathy that may occur because of mechanical compression of the nerve, usually at its exit from the crural fascia. The symptoms include sensory alterations over the distribution area of the superficial peroneal nerve. Clinical examination, electrophysiologic findings, and imaging techniques can establish the diagnosis. Variations in the superficial peroneal sensory innervation over the dorsum of the foot may lead to variable results during neurologic examination and variable symptomatology in patients with nerve entrapment or lesions. Knowledge of the nerve's anatomy at the lower leg, foot, and ankle is of essential significance for the neurologist and surgeon intervening in the area.

Branching patterns and localization of the common fibular (peroneal) nerve: an anatomical basis for planning safe surgical approaches

PURPOSE

Given the severity and incidence of injury to the common fibular (peroneal) nerve (CFN), there is a need to further clarify its anatomical location and branching patterns. This project attempts to consolidate current anatomical understanding of this nerve and provide physicians with reproducible measurements regarding the CFN and its branches.

METHODS

Dissections were performed on 50 specimens (28 cadavers), both fresh and preserved. The CFN was dissected from its emergence from the fibular tunnel to its anterior tibial recurrent nerve (ATRN), superficial fibular nerve (SFN), and deep fibular nerve (DFN) branches. The CFN branching patterns were assessed and all variations were categorized into four types.

RESULTS

Several significant relationships were identified between observable traits and key anatomical characteristics of the CFN. A significant correlation was found between fibular length and distance from the tip of the fibula to the DFN/ATRN branch, as well as between fibular length and distance from the tibial tuberosity to the SFN/DFN and DFN/ATRN branches. An association was identified between length of exposed sub-cutaneous CFN and height. Thickness of the biceps femoris tendon correlated significantly with BMI.

CONCLUSIONS

These findings allow physicians to better assess a patient's individual CFN anatomy based on correlations with measureable physical traits and will contribute to anatomic education and successful completion of various surgical, anesthetic, and physical therapy procedures.

Damage to the superficial peroneal nerve in operative treatment of fibula fractures: straight to the bone? Case report and review of the literature

Ankle fractures are a significant part of the lower extremity trauma seen in the emergency department. Neurologic complications of ankle fracture surgery are infrequently described but account for significant morbidity. The risk of nerve injury is increased for the Blair and Botte type B pattern of the intermediate cutaneous dorsal nerve branch, crossing the distal fibula from posterior to anterior (at 5 to 7 cm from malleolar tip). This pattern is present in about 10% to 15% of patients. Injuries to the superficial peroneal nerve and its branches negatively influence the outcome. Early recognition and protection might reduce the incidence of superficial peroneal nerve injuries during open reduction and internal fixation of lateral malleolus fractures. We describe 2 surgically treated ankle fractures with superficial peroneal nerve branch (intermediate cutaneous dorsal nerve) involvement and review the current literature.

Lateral leg compartment syndrome caused by ill-fitting compression stocking placed for deep vein thrombosis prophylaxis during surgery: a case report

Isolated lateral leg compartment syndrome is a relatively rare event, with potentially devastating consequences. We present a case of a 44-year-old man with isolated lateral leg compartment syndrome caused by a compression stocking used for deep vein thrombosis prophylaxis during surgery. It was found to be excessively tight around the patient's proximal calf postoperatively. He underwent lateral leg compartment fasciotomy and delayed wound closure with a split-thickness skin graft. At the 7-month follow-up visit, he had returned to full activity, had no muscle deficits, and had numbness in the distribution of the intermediate dorsal cutaneous nerve.

Diagnostic value of delineating deep fascia in distinguishing between benign and malignant soft-tissue tumors in lower limbs using 3.0 T magnetic resonance imaging

PURPOSE

To determine the association between morphological changes to the deep fascia and the malignancy of soft-tissue tumors in the lower limbs using 3.0 T magnetic resonance imaging (MRI).

MATERIALS AND METHODS

MR images of 47 consecutive patients with 48 pathologically proven soft-tissue tumors in the lower limbs were retrospectively reviewed by two radiologists. Lesions were divided into four groups according to their predominant location relative to the deep fascia: Group A: subcutaneous lesions superficial to the deep fascia (n = 9); Group B: lesions located beneath the deep fascia (n = 8); Group C: lesions centered in the interspaces of the deep fascia investment (n = 11); and Group D: intramuscular lesions (n = 20).

RESULTS

The deep fascial structures were complete in all of the 19 benign lesions. In malignant lesions, destruction signs of the deep fascia were observed in 27 of the 29, which were characterized by disappearance/disruption of the fascial line and aggressive growth penetrating through the fascial line into the adjacent compartment, or disappearance/disruption of the intermuscular septa and embedding the mutilated fascial septa within the lesion, or destruction of the fascia-muscle planes and abolishment of the deep fascial interspaces. Diagnosis of malignancy based on the signs of destruction of the deep fascial structure delineated with 3.0 T MRI, the sensitivity, specificity, and accuracy were 93.10%, 100%, and 95.83%, respectively.

CONCLUSION

Tumor involvement and destruction of the deep fascial structures visualized by 3.0 T MRI may be of utility in differentiating malignant from benign soft-tissue tumors.