Toe extensor weakness resulting from trivial athletic trauma. Report of three unusual cases

The current trend of proximal tibiofibular ganglion cyst: A summary of 7 case series and 61 case reports

Purpose

To review the different types of ganglion cysts surrounding the proximal tibio-fibular joint, their management options, outcomes, and recurrence.

Design

Descriptive analytical review.

Results

7 case series consisting of a total of 159 patients and 61 case reports consisting of 80 patients (with three patients having bilateral pathology) were included in this review. (Total cysts 159 + 83 = 242). The mean age was 41 years, and 71 % of the patients were males. 96.5 % of the cases were managed operatively, out of which 98 % of patients felt improvement in local symptoms and 71.5 % had improvement in neurological symptoms. Complete excision of the cyst is the primary mode of operative management. Many added procedures with complete excision are to mitigate the risk of recurrence. The recurrence rate of aspiration, simple excision alone, simple excision with recurrent articular branch neurectomy, and simple excision with PTFJ procedures were 77 %, 56 %, 11.5 %, and 0 %, respectively. Outcomes beyond recurrence were poorly reported.

Conclusion

There is not enough literature regarding the topic from which any formal systematic review can be done. Our summary suggests that aspiration alone or with steroid injection is associated with the highest recurrence rates among all the procedures. Complete excision with recurrent articular branch neurectomy should be the primary management. Revision cyst excision in isolation is an inadequate treatment option, therefore should be done in conjunction with PTFJ arthrodesis, which reduces the recurrence rates. Better quality studies are needed that report patient-centered outcomes and morbidities following PTFJ procedures.

De novo footdrop resulting from an isolated acute repetitive strain injury

OBJECTIVES

To report a case of a teenage boy (N.K.) who had a peroneal nerve palsy after an isolated repetitive stain injury from an episode of sustained repetitive kicking and to explore the emergency physician's approach to footdrop or absent dorsiflexion.

METHODS

Chart review.

RESULTS

N.K. presented to the emergency department (ED) with right footdrop, inability to dorsiflex. Results of investigations in the ED, including radiographs of his lumbar spine and knees and a magnetic resonance imaging scan of the lumbar spine, were all normal. Electromyography showed that the extensor digitorum brevis muscle was borderline prolonged at 4.1 m/s for 65 mm, whereas the distal latency of the tibial nerve to abductor hallucis muscle was prolonged at 4.8 milliseconds for 7 cm. There were increased insertional activity and 2+ fibrillation potentials in EDB, but motor units were normal, as was recruitment. There was no conduction velocity slowing across the fibular head segment of the peroneal nerve. N.K. did not need any further follow-up because his function was completely regained.

CONCLUSIONS

Repetitive strain injury, even in acute settings may predispose one to developing a peroneal neuropathy. As in the case of N.K., most cases resolve in weeks to months, and electromyography studies are important to help definitively decide what type of neuronal injury has been sustained.

Acute onset of deep peroneal neuropathy during a golf game resulting from a ganglion cyst

We report a case of sudden onset of deep peroneal neuropathy resulting from a ganglion cyst. Electrophysiology demonstrated a severe deep peroneal neuropathy with axonal loss and probably proximal conduction block. Magnetic resonance imaging demonstrated a mass arising from the proximal tibiofibular joint extending along the peroneal nerve. Surgical resection of the ganglion resulted in gradual improvement of strength. Peroneal nerve ganglia should be considered in the evaluation of patients with sudden painless foot drop.

Peripheral nerve fascicles: Anatomy and clinical relevance

Within a peripheral nerve, the individual nerve fibers are grouped together in fascicles. Whether there is somatotopic organization within these fascicles has long been of interest, the subject of many investigations, and somewhat controversial. Evidence from diverse sources now points to important somatotopic clustering of nerve fibers within most of the length of the nerve. Information is lacking regarding proximal segments, particularly the plexus and spinal nerve root levels. As a result of this somatotopic arrangement, partial focal nerve lesions can produce restricted clinical deficits that defy the classic rules of localization. Examples of such restricted nerve lesions are provided in this review. Recognition of fascicle somatotopy is also important in the surgical approach to disorders of peripheral nerves.

Isolated weakness of the extensor hallucis longus in a patient with hereditary spherocytosis

A 24-year-old woman with a history of hereditary spherocytosis and oral contraceptive use presented with a spontaneous, isolated loss of great toe extension. She had clinical and electrodiagnostic evidence of a localized lesion affecting the nerve supply to the extensor hallucis longus (EHL). Full clinical recovery was apparent within 6 months with nonoperative therapy. Isolated EHL weakness may occur as a rare neurologic complication of procedures such as high tibial osteotomies, but, to our knowledge, this has not been reported in the absence of trauma or surgery. While the coexistence of hereditary spherocytosis and a peripheral neuropathy may have been purely coincidental, it is plausible that the isolated lesion in this patient was due to ischemic changes from underlying rheologic conditions, possibly in association with a variation in the neural or nutrient vessel supply to the EHL.