The consistent presence of the human accessory deep peroneal nerve

Twenty-four human legs were dissected macroscopically to study the morphological details of the accessory deep peroneal nerve. This nerve arose from the superficial peroneal nerve and descended in the lateral compartment of the leg, deep to peroneus longus along the posterior border of peroneus brevis. Approaching the ankle joint, this nerve passed through the peroneal tunnels to wind around the lateral malleolus; it then crossed beneath the peroneus brevis tendon anteriorly to reach the dorsum of the foot. The accessory deep peroneal nerve was found in every case examined and constantly gave off muscular branches to peroneus brevis and sensory branches to the ankle region. In addition, this nerve occasionally had muscular branches to peroneus longus and extensor digitorum brevis, and sensory branches to the fibula and the foot. The anomalous muscles around the lateral malleolus were also innervated by this nerve. Neither cutaneous branches nor communicating branches with other nerves were found. The present study reveals that the accessory deep peroneal nerve is consistently present and possesses a proper motor and sensory distribution in the lateral region of the leg and ankle. It is not an anomalous nerve as has previously been suggested.     

Bilateral accessory flexor digitorum longus muscle in man

An accessory muscle (flexor digitorum longus accessorius) was encountered in the deep posterior compartment of both legs of a 57-year-old male cadaver. The muscle originated with two heads from the medial margin of the tibia, lateral margin of the fibula, posterior intermuscular septum and the deep fascia at the distal part of the leg. Both heads came together just posterior and superficial to the tibial nerve, and converged into a slender tendon which traversed the tarsal tunnel in the vicinity of the neurovascular bundle to reach the sole of the foot. It terminated by merging into the tendon of the quadratus plantae muscle. The potential of such an anomalous muscle to lead to misinterpretations of the radio-diagnostic examinations and the fact that it can be one of the causes of tarsal tunnel syndrome should be borne in mind.     

Fascicular analysis at perineurial level of the branching pattern of the human common peroneal nerve

The macroscopic branching pattern of the peripheral nerves is usually provided by the epineurial connective tissue, whereas the removal of the epineurium discloses component fascicles covered by a perineurial sheath comprising a fine network with a peculiar branching pattern. In order to compare both patterns, the common peroneal nerve (PC) was dissected minutely in 10 human legs. At the epineurial level the branching pattern into tributary bundles was variable in respect to both the origin of the superficial peroneal nerve and that of the muscular branches (Rr. m. peroneus longus, RPL) to the peroneus longus. At the perineurial level the fascicles formed intricate tiny plexuses without a discrete branching pattern, but as a whole consisted of a regular arrangement divided into four crural streams for the deep peroneal (PP), the accessory deep peroneal (PPA) and two dorsal cutaneous nerves. The RPL fascicles were derived substantially from the PPA stream. The findings on the fascicular branching pattern in the present study show that the PC consists of two muscular and two sensory streams that were ensheathed by the epineurium to form the PP containing a single muscular stream, and the superficial peroneal nerve with the three remaining streams. Thus the extensor and peroneal muscles of the leg have their own nerve supply from the PP and PPA, respectively. The branching pattern of the fascicles of muscular branches at the perineurial level may be a useful estimator of muscle grouping, for which the branching pattern at the epineurial level is hardly of any use due to its variability.     

Unique distribution by the peroneal nerves: a case report

Purpose

Among the branches of common peroneal nerve, the superficial peroneal provides cutaneous innervation to major part of the dorsum of the foot and deep peroneal nerve supplies the skin over the first interdigital cleft region.

Methods

The present rare case was observed during routine dissection of leg for undergraduate students, in a 52-year-old male, formalin fixed cadaver.

Results

The superficial peroneal nerve provided solely motor branches to peroneus longus and brevis, whereas cutaneous branches were provided by deep peroneal nerve. In the lower one-third of the leg deep peroneal nerve divided into medial and lateral branches. The medial branch supplied tibialis anterior and the lateral branch supplied skin of medial three and half toes. Moreover, the sural nerve supplied the skin of lateral one and a half toes.

Conclusion

Awareness of this type of variations in the course of nerves helps to alert the surgeons when there are complaints of atypical or unique pain in that particular region.     

Central representation of the hindlimb muscles supplied by the common peroneal nerve. A retrograde horseradish peroxidase study in the dog

Motoneurons supplying the common peroneal nerve in the dog were identified by the retrograde horseradish peroxidase method. They were distributed within two discrete cell columns (columns 2 and 2') in the 6th and 7th lumbar segments. The extensor digitorum longus muscle was represented in the dorsolateral part of column 2; the peroneus longus muscle in the ventrolateral part and the tibialis cranialis muscle in the intermediate lateral part. The medial half of column 2 contained motoneurons supplying the superficial peroneal nerve. Column 2', which was situated dorsomedially to column 2, contained motoneurons innervating the extensor digitorum brevis muscle.     

Dimensions of the anterior tarsal tunnel and features of the deep peroneal nerve in relation to clinical application

Background The aim of this study was to demonstrate anatomical features of the anterior tarsal tunnel and the deep peroneal nerve and to discuss the importance of these structures for the anterior tarsal tunnel syndrome and some other surgical approaches to minimize the injury risk. Methods Lower limbs of 18 formalin fixed cadavers were examined. The limbs showed no evidence of pathology or trauma. Results The lateral length of the tunnel was 21.7 ± 4.3 mm and the medial length of the tunnel was 55.0 ± 9.0 mm. The width of the tunnel at the inferior border between the extensor hallucis longus and extensor digitorum longus tendons was 12.6 ± 2.1 mm. The location of the deep peroneal nerve bifurcation was in the anterior tarsal tunnel in 31 specimens (86.1%) and distal to the tunnel in two specimens (5.6%). In three specimens (8.3%) there was no bifurcation because of the absence of the medial terminal branch of the deep peroneal nerve. In these three specimens, the superficial peroneal nerve distributed to the adjacent sides of the great and second toes. Bifurcation above the tunnel was not observed in our specimens. There was connection between the deep peroneal nerve and the superficial peroneal nerve in 10 specimens (27.8%) in the first interdigital space. During the observations, the presence of a fibrous band over the nerve and vessel was noted in 22 specimens (61.1%). Conclusions We believe that a detailed anatomic knowledge of the anterior tarsal tunnel and the deep peroneal nerve will be of help during surgical approaches to this area and the diagnosis of the problems related to the peripheral nerves on the dorsum of the foot. This study was presented on the 4th Asian-Pacific International Congress of Anatomists (APICA 2005) in Kusadasi, Turkey on 7-10 September 2005.     

Anterior tarsal tunnel syndrome

Three hundred twenty patients complaining of pain and/or numbness of their feet were evaluated in our Clinical Neurophysiology Laboratory. Nerve conduction studies of deep peroneal, superficial peroneal, sural and posterior tibial nerves were studied bilaterally. Needle electromyography (EMG) of anterior tibial, long peroneal, abductor hallucis longus, extensor hallucis longus, gastrocnemius and extensor digitorum brevis muscles were examined bilaterally. Nerve conduction studies of 25 healthy volunteer subjects (16 female, 9 male, age range 36-70, mean age 52.82 +/- 8.8) with no complaint composed the control group. Fourteen of these patients (8 female, 6 male, age range 40-70, mean age 55.73 +/- 12.04) were found to have anterior tarsal tunnel syndrome (anterior TTS) bilaterally or unilaterally. In the patients with anterior TTS, the nerve conduction studies revealed deep peroneal nerve distal latency as 6.5 +/- 1.9 msec; the amplitude as 1.8 +/- 1.3 mV at the ankle level; and the conduction velocity as 41.5 +/- 5.9 m/sec in the distal segment. When these values were compared with the control group statistically, results were found highly significant (p < 0.005). Needle EMG findings in the anterior TTS group showed only in the extensor digitorum brevis muscle. Other nerves and muscles were normal. All patients with anterior TTS were performing Namaz for years, and none of them had the predisposing factor which may cause entrapment neuropathy. So, we suggest that chronic prolonged stretching of the deep peroneal nerve on the dorsum of the foot during Namaz may cause anterior TTS.     

Anatomic basis of a pedicled extensor digitorum brevis muscle flap

The vascularization of the extensor digitorum brevis is ensured on its deep aspect by branches of the anterior tibial artery, but also by a lateral arterial arch anastomosing with these branches. The lateral vascular arch of the extensor digitorum brevis was constantly found in 37 anatomic specimens: 17 formolized and 20 fresh. This arch derives from the perforating peroneal branch, the terminal anterior branch of the peroneal artery. Its variable caliber, assessed by arteriography of the foot, seemed adequate for the peroneal artery to serve as a pedicle for the extensor digitorum brevis without interruption of the anterior-tibial axis.     

Enlarged perforating branch of peroneal artery and extra crural fascia in close relationship with the tibiofibular syndesmosis

We found an extremely large perforating branch of peroneal artery in an 89-year-old female cadaver’s left ankle. The anterior tibial artery could not reach to supply the ankle and dorsum of the foot. The perforating branch of peroneal artery continued as the dorsalis pedis after giving off an anterior lateral malleolar artery branch. The posterior tibial artery was thinner than usual. On the anterior side of the ankle, there was an extra crural fascia in addition to the regular crural fascia, under the anterior crural muscles. This strong fascia was tightly overlying the perforating branch of peroneal artery and anterior tibiofibular ligament. It is important to know the relationship of these vessels to the surrounding structures. Surgeons must be careful while dissecting this area since the perforating branch of peroneal artery might be anomalously enlarged as well as crossing in front of the tibiofibular syndesmosis in order to prevent vascular injury.This study presented as poster presentation at “22nd Annual Meeting of the American Association of Clinical Anatomists and 4th Joint International Meeting with the British Association of Clinical Anatomists July 20–23, 2005, New York City, NY, USA”.     

Nerve conduction velocity to different muscles in peroneal pressure neuropathy.

The variability inherent in nerve conduction velocity (NCV) studies suggests that multiple measurements may yield more information than a single measurement. To test this hypothesis, three motor nerve conduction velocities (NCVs) of the peroneal nerve were measured: to the extensor digitorum brevis muscle over the fibular head and in the lower leg, and to the tibialis anterior muscle over the fibular head. Three groups were studied: controls, polyneuropathy cases and peroneal pressure neuropathy cases. Over the fibular head, NCVs recorded from the tibialis anterior were consistently higher than those from the extensor digitorum brevis, and showed a higher number of abnormalities. Differences between NCVs, their Z-scores and Mahalanobis distances were compared to study the influence of variance differences and covariances. The best compromise between true and false positives was found to be a comparison between NCVs over the fibular head recorded from the tibialis anterior and the leg segment recorded from the extensor digitorum muscle. Z-scores are more useful than Mahalanobis distances in this respect.     

Superficial fibular nerve variations of fascial piercing: A meta‐analysis and clinical consideration

The superficial fibular (peroneal) nerve (SFN) is one of the successive branches of the common fibular (peroneal) nerve and goes on to bifurcate into the medial dorsal cutaneous (MDN) and intermediate dorsal cutaneous (IDN) nerves. The SFN is a main contributor to sensory innervation of the foot and lower leg. It varies widely in its penetrance of the deep (crural) fascia, and differences in its subsequent course can result in iatrogenic injuries. Articles on the prevalence of this anatomical variation were identified by a comprehensive database search. The data collected were extracted and pooled into a meta‐analysis. A total of 14 articles (n = 665 lower limbs) were included on the meta‐analysis of SFN variations in fascial piercing. The normal Type 1 variation, where the SFN pierces the deep fascia as a single entity and later bifurcates into the MDN and IDN, had a pooled prevalence of 82.7% (95%CI: 74.0–89.4). The Type 2 variant, where the SFN bifurcates early and then pierces the fascial layer separately as the MDN and IDN, had a pooled prevalence of 15.6% (95%CI: 8.9–23.6). Type 3, when the SFN penetrates the deep fascia and courses similar to the MDN with absent IDN was noted in 1.8% (95%CI: 0.0–4.9) of cases. A substantial portion of the population has a pattern of SFN piercing that deviates from the normal Type 1 anatomy. It is recommended that possible SFN variants in patients should be addressed thoroughly to help prevent iatrogenic injuries and postoperative complications. Clin. Anat. 30:120–125, 2017. © 2016 Wiley Periodicals, Inc.     

The possibility of deep peroneal nerve neurotisation by the superficial peroneal nerve: an anatomical approach

Neurotisation involves transfer of nerves for the restoration of function following injury. A number of nerves have been used in different part of the peripheral nervous system. This study was undertaken to develop a practical and relatively safe surgical approach to the treatment of L4 root lesion's. We examined the effectiveness and safety of neurotisation of the deep peroneal nerve and its branches by the superficial peroneal nerve. Twelve legs of dissected cadavers provided for teaching purposes in the anatomy laboratory were used to display the common peroneal nerve and its branches. Each branch was measured using calipers and analysed to investigate the possibility of neurotisation of the deep peroneal nerve by the superficial peroneal nerve and its branches. It was found that of the measured branches, transposition was possible between those to peroneus longus and tibialis anterior on the basis of their diameter and length. In recent decades, advances in microsurgical reconstruction and understanding of the microanatomy have played major roles in improving the results of surgical treatment of nerve injuries. There is a need for further experimental studies on the feasibility of this surgical approach.     

远端蒂腓浅神经营养血管肌皮瓣的解剖与临床应用

目的探讨腓浅神经营养血管为蒂的肌皮瓣修复小腿远端及足踝部皮肤软组织缺损伴骨缺损慢性骨髓炎的解剖学依据及其临床应用效果。方法对30侧成人下肢灌注标本进行解剖,系统观测腓浅神经及其营养血管的来源、走行、分布、吻合及外径;3侧成人新鲜下肢标本墨汁灌注,观测腓浅神经营养血管的墨染范围;在此基础上,自2009年6月以来,应用远端蒂腓浅神经营养血管肌皮瓣修复小腿远端及足踝部皮肤软组织缺损伴骨缺损慢性骨髓炎者12例。结果腓浅神经营养血管发自胫前动脉穿支,其血管在其神经束间及神经旁相互吻合构成丰富的血管网,并借分支与皮下筋膜血管网沟通,并与腓骨长肌、趾长伸肌的肌支有恒定的吻合,营养筋膜皮肤。12例肌皮瓣的肌肉面术中可见渗血活跃,血供良好,皮瓣均成活,术后3~6个月随访12例肌皮瓣均存活,慢性骨髓炎治愈,外形满意。结论腓浅神经营养血管的肌皮瓣转位修复小腿远端及足踝部特殊创面是较佳的选择,该肌皮瓣具有血供可靠,预后良好等优点。     

Stumbling corrective reaction during fictive locomotion in the cat

An obstacle contacting the dorsal surface of a cat's hind foot during the swing phase of locomotion evokes a reflex (the stumbling corrective reaction) that lifts the foot and extends the ankle to avoid falling. We show that the same sequence of ipsilateral hindlimb motoneuron activity can be evoked in decerebrate cats during fictive locomotion. As recorded in the peripheral nerves, twice threshold intensity stimulation of the cutaneous superficial peroneal (SP) nerve during the flexion phase produced a very brief excitation of ankle flexors (e.g., tibialis anterior and peroneus longus) that was followed by an inhibition for the duration of the stimulus train (10-25 shocks, 200 Hz). Extensor digitorum longus was always, and hip flexor (sartorius) activity was sometimes, inhibited during SP stimulation. At the same time, knee flexor and the normally quiescent ankle extensor motoneurons were recruited (mean latencies 4 and 16 ms) with SP stimulation during fictive stumbling correction. After the stimulus train, ankle extensor activity fell silent, and there was an excitation of hip, knee, and ankle flexors. The ongoing flexion phase was often prolonged. Hip extensors were also recruited in some fictive stumbling trials. Only the SP nerve was effective in evoking stumbling correction. Delivered during extension, SP stimulus trains increased ongoing extensor motoneuron activity as well as increasing ipsilateral hip, knee, and ankle hindlimb flexor activity in the subsequent step cycle. The fictive stumbling corrective reflex seems functionally similar to that evoked in intact, awake animals and involves a fixed pattern of short-latency reflexes as well as actions evoked through the lumbar circuitry responsible for the generation of rhythmic alternating locomotion.     

The peroneus quartus muscle: clinical correlation with evolutionary importance

The peroneus quartus (PQ) is an accessory muscle of the peroneal/lateral compartment of the leg. The muscle has often been implicated as a cause of pain in the lateral ankle region, and subluxation or attrition of the peroneal tendons. The present study was aimed at observing the prevalence and morphology of this muscle in human cadavers. Ninety-two embalmed lower limbs were dissected for this study. The PQ muscle was found in 21% of the limbs. In all these limbs it originated from the lower part of the lateral surface of the fibula, the undersurface of peroneus brevis and the posterior intermuscular septum. In the majority of limbs, insertion was on the retrotrochlear eminence of the calcaneus. Taking into account the possibility of this muscle being a cause of lateral ankle pathology, the present study attempts to correlate the findings with the anatomy of the surrounding region. The frequent occurrence of this muscle in humans is suggestive of a progressive evolutionary change to evert the foot in order to assume a bipedal gait.     

逆行腓骨肌肌皮瓣设计的解剖学研究

目的　为逆行腓骨肌皮瓣的设计与临床应用提供解剖学依据。 方法 新鲜下肢标本20侧,动脉灌注红色乳胶,解剖观测腓动脉、腓骨长肌、腓骨短肌及其表面皮肤与营养血管的的起始、走行、分支、分布的情况;新鲜标本2具,动脉灌注乳胶、氧化铅混悬液,CT扫描后三维重建小腿与足部血管。 结果 腓动脉起始外径(3.7±0.7) mm,多条分支供给比目鱼肌、 长屈肌、腓骨长、短肌及表面皮肤。腓动脉穿支的血管蒂可游离长度为(3.5±1.3) cm。腓动脉终末穿支在胫腓骨骨间膜中穿出,外径(1.2±0.4)mm,分为升支和降支。腓骨短肌肌腹的上部有一支较粗的腓浅动脉发自胫前动脉,向前穿骨间膜行于腓骨长肌与小腿前群肌之间,管径(1.8±0.5) mm,行向下营养腓骨短肌、腓浅神经和小腿前外侧部皮肤。 结论 以腓动脉中、下部穿支或终末穿支与其它血管的吻合部为蒂,可以设计切取逆行腓骨长、短肌肌皮瓣,修复小腿下部及足背部软组织缺损。     

An unique variation of the peroneus tertius muscle

Peroneus tertius (fibularis tertius) is a muscle unique to humans. It often appears to be a part of extensor digitorum longus, and might be described as its "fifth tendon". Although its insertion variation has been reported by many authors, variations of its origin points are not common. A variation of the peroneus tertius muscle was found during routine dissection of a 75-year-old male cadaver. The muscle originated from the extensor hallucis longus. The muscle belly of the extensor hallucis longus arose from the middle two-fourths of the medial surface of the fibula, medial to the extensor digitorum longus, and anterior surface of the interosseous membrane. It lay under the extensor digitorum longus, and lateral to the tibialis anterior muscle. The muscle belly of the extensor hallucis longus divided into medial and lateral parts 17 cm below its origin point. The lateral part, named as peroneus tertius, continued downward to reach the medial part of the dorsal surface of the base of the fifth metatarsal bone. The medial part ran also downward and divided into two tendons reaching the dorsal surface of the base of the distal phalanx of the great toe. This kind of variation may be important during foot or leg surgery.     

Anatomy of the superficial peroneal nerve related to the harvesting for nerve graft

The superficial peroneal nerve (SPN) is one of the two main branches of the common peroneal nerve, which become cutaneous nerve on the lateral side of distal leg and dorsum of foot. The use of SPN as nerve graft has been introduced; however, important data regarding the morphometric anatomy of this nerve and its branches, medial and intermediate dorsal cutaneous nerves (MDN and IDN, respectively) to support this application remain incomplete. Eighty-five legs of cadavers were dissected and the branching pattern was classified into Type 1 (penetration of the main trunk of SPN from the deep fascia) or Type 2 (separate penetration of the MDN and IDN). The length of SPN, MDN and IDN from the penetration points until before subsequent branching was measured. In addition, the penetration points were located by referring to the intermalleolar line and the lateral malleolus. Type 1 was found in the majority of specimens independent of gender (71.8%). Asymmetry in the branching pattern was observed in nine cases (20.9%). The average length of the SPN, MDN and IDN without branches was 7.7, 8.1 and 5.5 cm, respectively. The penetration points of the SPN, MDN and IDN were located 5.1, 7.6 and 5.5 cm above the intermalleolar line, respectively. These data are important for using the SPN as a graft.     

Morphology of peroneus tertius muscle

Peroneus tertius (PT) muscle is peculiar to man, and man is the only member among the primates in whom this muscle occurs. The muscle is variable in its development and attachment. Because of functional demands of bipedal gait and plantigrade foot, part of extensor digitorum brevis (EDB) has migrated upwards into the leg from the dorsum of foot. PT is a muscle that evolution is rendering more important. In a total of 110 cadavers, extensor compartment of leg and dorsum of foot were dissected in both the lower limbs and extensor digitorum longus (EDL), and PT muscles were dissected and displayed. PT was found to be absent in 10.5% limbs, the incidence being greater on the right side. The remaining limbs in which the PT muscle was present had a very extensive origin from lower 3/4th of extensor surface of fibula (20% on right and in 17% on left), and the EDL was very much reduced in size. In approximately 12%, the tendon of PT was thick or even thicker than the tendon of EDL. In 4%, the tendon extended beyond fifth metatarsal up to metatarsophalangeal joint of fifth toe, and in 1.5%, it extended up to the proximal phalanx of little toe. In two cases (both on the right side), where PT was absent, it was replaced by a slip from lateral margin of EDL. We conclude that PT, which is preeminently human, is extending its purchase both proximally and distally.     

Secondary evoked muscle potential mapping according to the F, H, HF, FH features of nonexistence in proximal and distal limb muscles. A preliminary communication

In 62 healthy volunteers, a late response analysis was done in 23 leg and arm muscles. The potentials were differentiated according to their H-potential or F-potential features. The total disappearance of secondary potential was estimated also. The H-potential appeared most frequently in the thigh muscles (100%), frequently in the calf and peroneus longus muscles (77%-23%), rarely in the intrinsic foot muscles (20%), and never in the short or long foot and toe extensors. In the arms the H potential was most frequently found in flexor digitorum sublimis (67%). Its appearance in pronator quadratus was 22%. H-potential appeared rarely in the intrinsic hand muscles and never in the extensor digitorum communis. The similarity of H-wave distribution in the lower leg and feet muscles, and the lower arm and hand muscles is pointed out. The question of its phylogenetic determination is raised.