Common peroneal nerve palsy: an unexpected complication of liver surgery

BACKGROUND: Common peroneal nerve palsy is a well-recognized complication following surgery in lithotomy position, particularly colorectal and gynecologic surgery. But it is quite rare after liver surgery because patients are usually placed in supine position. CASE REPORT: There were three cases of common peroneal nerve palsy after liver surgery in the past 2 years, including two cases of liver transplantation and one case of extended right hepatectomy. Two cases were bilateral and one case was unilateral. They were placed in supine position and the mean operative time was 8 hours. Patients complained symptom of foot drop within 1 week after operation. Electromyographic examinations showed evidence compatible with common peroneal nerve palsy. All of them improved with conservative treatment within 6 months. CONCLUSION: Common peroneal nerve palsy may develop after liver surgery even in supine position. Injury to common peroneal nerve should be a concern before and during the operation. This complication could be managed conservatively with an uneventful result.     

Bilateral peroneal nerve injuries in a patient with bilateral femur fractures: a case report

The second reported case in the current literature of peroneal nerve palsy in bilateral femur fractures is described. This is the first case report of bilateral nerve palsies occurring in bilateral femoral fractures and the first report of bilateral peroneal nerve palsy associated with bilateral skeletal traction.     

Peroneal nerve palsy after ankle sprain: an update

Ankle sprains are extremely common in the general population and the most common injuries in athletes. Although rare, peroneal nerve palsy may occur simultaneously with ankle sprain. The exact incidence of nerve injury after ankle sprain is not known; few cases of peroneal nerve palsy associated with ankle sprains have been reported in the literature. The function of the peroneal nerve should be evaluated in all patients with a history of inversion ankle sprain as part of the initial and follow-up evaluation, even if the initial neurological status is normal, because delayed peroneal nerve palsy is possible. This article discusses the incidence, pathophysiology, evaluation, diagnosis and differential diagnosis, and management of the patients with peroneal nerve palsy after ankle sprain aiming to increase the awareness of the treating physicians for this nerve injury.     

Congenital clubfoot with concomitant peroneal nerve palsy in children

We investigated the prognosis and clinical importance of concomitant peroneal nerve palsy in congenital clubfoot. Six children (6 feet) with concomitant peroneal nerve dysfunction treated by various means and with no other related syndrome or neuromuscular disorder were studied. Their clinical outcomes and their parents' satisfaction with the outcome were assessed. Patients' average age at initial diagnosis was 5.1 months (range, 2 weeks to 13 months). The average length of follow-up was 67.4 months (range, 1-11 years). Nerve conduction velocity tests and electromyography were performed in six patients; serial cast correction, followed by application of an orthosis and periodic observation, was followed in two patients; and additional surgical correction was done in four patients whose deformity was not corrected by casting and an orthosis. None of the six patients recovered from peroneal nerve palsy and their parents reported a low level of satisfaction with the outcome of the treatment. It is important to detect the rare combination of peroneal nerve palsy and clubfoot, and to explain the poor prognosis to patients' parents before treatment.     

Supracondylar fractures of the femur in children: closed reduction and percutaneous pinning of displaced fractures

The authors reviewed nine children with 10 displaced supracondylar femoral fractures that were treated by closed reduction and percutaneous pinning. The average age of the patients was 8.3 years (range 5-13). After removal of the pins and plaster at 5 weeks, full range of movement was regained within 3 weeks. At late follow-up (average 7.4 years [range 4-10]), seven of the eight patients reviewed (nine fractures) had a satisfactory result. One patient had a valgus deformity of 6 degrees. There was no growth plate arrest and no leg length discrepancy. Intra-articular pin placement was avoided, considering the different synovial attachments on the medial and lateral sides. One patient developed a common peroneal nerve palsy, and therefore a cadaver study was performed to determine whether movement of the knee after pin placement affected the nerve. Although the lateral pin did tether the iliotibial band, the common peroneal nerve was not affected.     

The surgical treatment of humeral shaft fractures

This is a study of 84 patients with upper arm fractures who were treated by plate osteosynthesis. The indication was mandatory in 9 patients with open fractures, 23 patients with primary radial nerve palsy on admission, 5 patients with radial nerve palsy after the initial treatment, 22 patients with pseudarthrosis and 7 patients who were polytraumatised. The operation was also indicated in 15 patients, because of the form of the fracture, in 3 patients with brachial plexus lesion, in 3 patients because it involved both upper arms and in 3 patients with segmental fractures. The 4.5 DCP was used in all these cases. All the cases of pseudarthrosis progressed to achieve bony union after the operation. There was no incidence of postoperative pseudarthrosis. We did encounter two cases (2.4%) of radial nerve palsy that required exploration. All the preoperative primary and secondary cases of radial nerve palsy recovered postoperatively. After an average follow-up period of 2.4 years (1-10 years) 90% of the patients could be classified as having very good or good results.     

Postarthroplasty "palsy" and systemic neuropathy: a peripheral-nerve management algorithm

Postarthroplasty palsy, occurrence of dysfunction of the sciatic or peroneal nerve after total joint replacement of the hip or knee, is a complication that remains poorly understood. Characteristics of a series of 24 patients with postarthroplasty palsy are reviewed, with the finding that, overall, 58.4% of the patients had an underlying peripheral neuropathy. The role of this neuropathy predisposing the arthroplasty patient to stretch/traction injury is discussed and should be emphasized as a risk factor prior to surgery and should influence the surgeon's intraoperative use of force during the arthroplasty procedure. This clinical problem is addressed from the perspective of peripheral nerve surgery, with an algorithm suggested for its management. The algorithm suggests that if a peroneal palsy is still present at 3 months after an arthroplasty and neurosensory testing fails to demonstrate a sensory reinnervation pattern in the territories of the deep or superficial peroneal nerve, then surgical neurolysis of the common peroneal nerve is indicated.     

Locked nailing of spiral humeral fractures with or without radial nerve entrapment

The experience of locked nailing of spiral humeral fractures and the perioperative conditions of the radial nerve are reported. The nerve is at risk of entrapment after such a fracture, and severe injury may occur during closed nailing. Among 162 humeral fractures treated by locked nailing, there were 21 spiral fractures: 18 acute fractures, and three delayed unions. The distribution of the fractures was two at the middle and 19 at the distal (1/3). Twelve patients had preoperative radial nerve palsy. All fractures excluding one middle fracture were retrograde nailed, and all patients had radial nerve exploration. Thirteen fractures were locked statically, seven were locked distally and had cerclage wiring, and one was locked distally only. Fisher's exact tests showed that the risk of radial nerve entrapment significantly increased in fractures with varus angulation or resulting from high-energy trauma. All the patients achieved fracture union and regained satisfactory joint functions. The author suggests that in external rotational spiral humeral fractures, radial nerve exploration should be done if nerve entrapment is highly suspected, irrespective of the fracture location or nerve palsy. Locked nailing with transfixing screws or cerclage wire could be a reliable treatment method for these fractures.     

Complications and outcomes of the transfibular approach for posterolateral fractures of the tibial plateau

ObjectiveEvaluate complication rates and functional outcomes of fibular neck osteotomy for posterolateral tibial plateau fractures.DesignRetrospective case series.SettingUniversity hospital.PatientsFrom January 2013 to October 2014, 11 patients underwent transfibular approach for posterolateral fractures of the tibial plateau and were enrolled in the study. All patients who underwent transfibular approach were invited the return to the hospital for another clinical and imaging evaluation.InterventionTransfibular approach (fibular neck osteotomy) with open reduction and internal fixation for posterolateral fractures of the tibial plateau.Main outcome measurementsComplications exclusively related to the transfibular approach: peroneal nerve palsy; knee instability; loss of reduction; nonunion and malunion of fibular osteotomy; and functional outcomes related to knee function.ResultsTwo patients failed to follow-up and were excluded from the study. Of the 9 patients included in the study, no patients demonstrated evidence of a peroneal nerve palsy. One patient presented loss of fracture reduction and fixation of the fibular neck osteotomy, requiring revision screw fixation. There were no malunions of the fibular osteotomy. None of the patients demonstrated clinically detectable posterolateral instability of the knee following surgery. American Knee Society Score was good in 7 patients (77.8%), fair in 1 (11.1%), and poor in 1 (11.1%). American Knee Society Score/Function showed 80 points average (60–100, S.D:11).ConclusionThe transfibular approach for posterolateral fractures is safe and useful for visualizing posterolateral articular injury. The surgeon must gently protect the peroneal nerve during the entire procedure and fix the osteotomy with long screws to prevent loss of reduction.Level of evidenceTherapeutic level IV.     

Acute shortening and re-lengthening in the management of bone and soft-tissue loss in complicated fractures of the tibia

We have managed 21 patients with a fracture of the tibia complicated by bone and soft-tissue loss as a result of an open fracture in 10, or following debridement of an infected nonunion in 11, by resection of all the devitalised tissues, acute limb shortening to close the defect, application of an external fixator and metaphyseal osteotomy for re-lengthening. The mean bone loss was 4.7 cm (3 to 11). The mean age of the patients was 28.8 years (12 to 54) and the mean follow-up was 34.8 months (24 to 75). All the fractures united with a well-aligned limb. The mean duration of treatment for the ten grade-III A+B open fractures (according to the Gustilo-Anderson classification) was 5.7 months (4.5 to 8) and for the nonunions, 7.6 months (5.5 to 12.5). Complications included one refracture, one transient palsy of the peroneal nerve and one equinus contracture of 10 degrees .     

Common Peroneal Nerve Palsy Due to Giant Fabella After Total Knee Arthroplasty

BackgroundCommon peroneal nerve palsy (CPNP) is a rare but serious complication following primary total knee arthroplasty (TKA). The common peroneal nerve is one of the main molecules of the sciatic nerve. CPNP is a series of symptoms caused by common peroneal nerve injury due to paralysis and atrophy of the fibula and tibia muscles. The main clinical symptoms are: ankle joint unable to extend back, toe unable to extend back, foot droop, walking in a steppage gait, and foot dorsal skin sensation having decreased or disappeared. If treatment is not timely, severe cases may result in atrophy of the anterior tibia and lateral calf muscles. The risk factors for CPNP include mechanical stretching of the nerve, disruption of the blood supply to the nerve, and compression of the nerve. The CPNP should be treated in a timely manner and according to the cause. Its function should be restored as soon as possible to avoid serious adverse consequences. It has negative effects on patients’ life and physical and mental health. To our knowledge, this is the first study to describe CPNP due to a giant fabella after TKA.Case presentationThe present study reported on a 70‐year‐old female patient. The patient underwent a primary TKA of the right knee for osteoarthritis. Relevant examinations were conducted and the operation went smoothly. Three hours postoperation, a right partial CPNP was observed, with progressive aggravation over time. On palpation, there was a 2 × 2‐cm fixed hard mass in the posterolateral aspect of the right knee, with mild tenderness to deep palpation. Radiographs demonstrated that a giant fabella was located at the posterolateral condyle of the right femur. Fabellectomy and neurolysis of the common peroneal nerve were performed. The peroneal nerve palsy resolved gradually after the operation. At 8‐month follow up after fabellectomy and neurolysis, the function of the common peroneal nerve had fully recovered.ConclusionsThe presence of giant feballa pressing on the common peroneal nerve should be considered when common peroneal nerve palsy occurs after TKA. Surgical exploration and release compression should be performed in a timely manner.     

初次全膝关节置换术后腓总神经麻痹的原因及处理

目的探讨初次全膝关节置换术（TKA）术后腓总神经麻痹产生的原因及处理。方法对2002年1月至2009年12月本院有完整记录的1257例初次TKA患者中术后出现腓总神经麻痹的病例进行回顾分析并随访14～56个月,其中一期双侧TKA 4例,单侧TKA 2例;术前诊断骨关节炎3例,类风湿关节炎2例,血友病关节炎1例。结果 6例（0.47%）术后出现腓总神经麻痹,可能的原因包括术中拉钩位置不当,术后血肿压迫,神经阻滞麻醉过程针刺伤,止血带时间过长,术后加压包扎过紧,严重膝外翻屈曲畸形矫形。5例（83.3%）完全恢复,1例行神经探查手术,术后症状一度加重,随访术后6个月运动功能恢复,但目前仍残留感觉麻木。结论初次TKA术后腓总神经麻痹是多种因素造成的,预防是关键,围手术期应注意识别可能发生的一些危险因素并谨慎操作。保守治疗可获得满意效果,神经探查手术应慎重。     

Comparison of initial nonoperative and operative management of radial nerve palsy associated with acute humeral shaft fractures

As a result of reading this article, physicians should be able to:1.Become familiar with the available treatment approaches for radial nerve palsy associated with humeral shaft fractures.2.Understand the strengths and limitations of the current treatment approaches for radial nerve palsy associated with humeral shaft fractures.3.Become familiar with the available evidence regarding the effectiveness of operative and nonoperative treatment for radial nerve palsy associated with humeral shaft fractures.4.Understand when operative or nonoperative management of radial nerve palsy associated with humeral shaft fractures may be appropriate.The optimal treatment approach for the initial management of radial nerve palsy associated with humeral shaft fractures has yet to be conclusively determined. The authors performed a systematic review of the literature to identify studies that compared the outcomes after initial nonoperative and operative management for radial nerve palsy associated with acute humeral shaft fractures. A meta-analysis of the data from these studies was also performed to determine whether recovery from radial nerve palsy was more favorable in one approach compared with the other. The primary outcome was recovery from radial nerve palsy and the secondary outcome was complaints after treatment. Nine articles (1 prospective observational and 8 retrospective) were included in the meta-analyses. Operative management showed no improved recovery from radial nerve palsy compared with nonoperative management. Nonoperative management was associated with a decreased risk of complaints relative to operative management. Recovery from radial nerve palsy associated with acute humeral shaft fractures is not influenced by the initial management approach.     

Peroneal nerve damage associated with the proximal locking screws of the AIM tibial nail

We report a case of division of the deep peroneal nerve resulting from a drill used in the insertion of an oblique proximal locking screw in an AIM tibial intramedullary nail (DePuy). Operative findings and anatomical study indicate there is a risk of damage to the peroneal nerve associated with the oblique proximal locking screws used in this nail design. If a patient has peroneal nerve palsy after nailing of the tibia, the possibility of nerve division should be considered, so that early exploration and repair of the nerve can be performed.     

Preventable iatrogenic cause of foot-drop in knee injuries with literature review

PurposeCommon peroneal nerve palsy is quite disabling and every effort should be made to prevent its injury during the treatment.MethodsWe retrospectively reviewed the prospectively collected data of 7 cases of tibial plateau fractures in association with proximal fibula fracture from January 2019 to September 2019 who presented to emergency room of our hospital.ResultsIn addition to fibular neck fracture, the first case had type 6 tibial plateau displaced fracture and the second case had displaced acetabular fracture with instability of knee with tibial tuberosity avulsion. common peroneal nerve palsy developed following application of distal tibial skeletal traction in both the cases. Other 6 such cases remained neurologically intact as traction was not applied to them.ConclusionSuch iatrogenic complication could have been prevented if the injury pattern of "concomitant medial and lateral columns" of the proximal leg is kept in mind by the treating surgeon before applying skeletal traction.     

Indications, dangers and results of surgical treatment of humeral shaft fractures

A series of 78 fractures of the humeral shaft is presented that were treated operatively between 1978 and 1987. Open fractures, fractures with primary palsy of the radial nerve, distal fractures with an intraarticular component, fractures in polytraumatized patients and non-unions were absolute indications for operative stabilization in this series. In 71 fractures, internal stabilization was performed and in 7 fractures external fixation. In 16 fractures (20.6%), primary palsy of the radial nerve was present. In 10 patients (12.8%), radial nerve palsy appeared postoperatively. Nonunions and deep infections did not occur. In two cases, a second osteosynthesis was necessary after loosening of the implants. The humeral shaft fracture shows normal bony consolidation after conservative treatment as well as appropriate plate osteosynthesis. Nine of the 16 patients with primary radial nerve palsy (56.2%) and 6 of the 10 patients with secondary radial nerve palsy (60%) had total functional recovery. In our series, intraoperative palsy of the radial nerve was the most frequent complication after dissection of spiroid fractures in the middle or lower third of the humeral shaft. In this fracture form, a more unstable osteosynthesis, such as intramedullary pinning in accordance to Hackethal, should be chosen.     

Sciatic nerve injury associated with fracture of the femoral shaft

The sciatic nerve escapes injury in most fractures of the femoral shaft. We report a case of sciatic nerve palsy associated with a fracture at the distal shaft of the femur. The common peroneal division of the sciatic nerve was lacerated by a bone fragment at the fracture site. Despite the delay in treatment, a satisfactory result was obtained.     

Extra-articular distal-third diaphyseal fractures of the humerus. A comparison of functional bracing and plate fixation

BACKGROUND: There are strong advocates for both operative and nonoperative treatment of distal-third diaphyseal fractures of the humerus, but there are few comparative data. We performed a retrospective comparison of these two treatment methods. METHODS: Fifty-one consecutive patients with a closed, extra-articular fracture of the distal one-third of the humeral diaphysis were identified from an orthopaedic trauma database. Forty patients were followed for at least six months or until healing of the fracture. Eleven patients were excluded because of inadequate follow-up. Nineteen patients had been managed with plate-and-screw fixation, and twenty-one had been managed with functional bracing. RESULTS: Among the operatively treated patients, one had loss of fixation, one had a postoperative infection, and one required tendon transfers for the treatment of a preoperative radial nerve palsy that did not resolve. Three new postoperative radial nerve palsies developed, and one had not resolved when the patient was last evaluated, three months after surgery. All operatively treated fractures healed with <10 degrees of angular deformity, and one patient lost 20 degrees of shoulder or elbow motion. Among the nonoperatively treated fractures, two were converted to plate fixation because of the treating surgeons' concern regarding alignment and radial nerve palsy. Only one patient had >30 degrees of malalignment in any plane. Two patients had development of skin breakdown during treatment and completed treatment in a sling. Two patients lost >/=20 degrees of elbow or shoulder motion. CONCLUSIONS: For extra-articular distal-third diaphyseal humeral fractures, operative treatment achieves more predictable alignment and potentially quicker return of function but risks iatrogenic nerve injury and infection and the need for reoperation. Functional bracing can be associated with skin problems and varying degrees of angular deformity, but function and range of motion are usually excellent.     

Synovial cysts of proximal tibiofibular joint causing peroneal nerve palsy: report of three cases and review of the literature

Introduction Synovial cyst of the proximal tibiofibular joint is a very rare condition, for which there is no consensus regarding treatment. Case presentation We present three patients who had synovial cysts of proximal tibiofibular joint that caused peroneal nerve palsy. We discuss the special features of synovial cysts and review the literature. Conclusion We consider the best treatment of synovial cysts originating from proximal tibiofibular joint and causing peroneal nerve palsy to be total surgical removal as soon as possible after the diagnosis is made. It should be kept in mind that despite surgical treatment the neurological symptoms may not recover.     

Fractures of the forearm resulting from low-velocity gunshot wounds.

Thirty-seven extraarticular fractures of the forearm resulting from low-velocity gunshot injuries were treated by cast immobilization or open reduction and internal fixation with dynamic compression plates. All patients received 72 h of intravenous antibiotics. There were 14 isolated ulna fractures, 17 isolated radius fractures, and six both-bone (radius and ulna) fractures. Cast immobilization was used in 22 of 23 nondisplaced or minimally displaced fractures and eight of 14 displaced fractures. The remaining seven fractures were treated by open reduction and internal fixation. All fractures united within 16 weeks of injury regardless of the method of treatment. Poor clinical results related to the fracture occurred in six patients, five of whom were treated by cast immobilization. Fourteen patients had nerve palsies; eight resolved spontaneously and six had permanent neurologic deficits. There were two compartment syndromes and one ulnar artery transection. There were no infections. We conclude that displaced fractures of the radius, and both bone fractures, are best treated by open reduction and internal fixation. All patients should be closely monitored for 24 h for compartment syndrome, regardless of the fracture type or pattern. Early dynamic splinting is important when associated nerve injuries are present.