踝关节外伤性腓总神经卡压综合征的治疗

目的探讨踝关节外伤性腓总神经卡压综合征的发生机制及治疗效果。方法对16例踝关节外伤性腓总神经卡压综合征进行综合治疗,其中11例保守治疗,5例进行手术治疗,术中发现腓总神经有不同程度的水肿、黏连,色泽苍白或暗淡,外膜增厚。结果本组均获随访,随访时间8个月～6年,平均4年。观察双下肢胫骨前肌、腓骨长短肌、伸足母长肌及伸趾长肌等肌力及小腿外侧、足背皮肤感觉恢复情况。16例患者腓总神经损伤的功能有不同程度恢复,其中优10例,良4例,可1例,差1例。结论对于踝关节损伤引起腓总神经卡压综合征予以保守治疗为主,但对于诊断完全性神经损伤保守治疗无效的患者及早行神经松解术,疗效比较满意。     

四肢神经卡压征的微创手术治疗

目的 介绍应用微创手术对四肢神经卡压征作神经松解术的特点及疗效。方法 对84例患者，4种神经卡压征(臂丛神经血管受压征、腕管综合征、肘管综合征和腓总神经卡压)在神经卡压部位作长3～5cm的小切口，用小直角拉钩的牵拉，潜行切断腕掌侧支持带、肘管及腓管，并扩大受压神经的显露部分。在放大6倍头戴式放大镜下对受压神经作神经外膜松解术。结果 术后随访3至24个月。21例臂丛神经血管受压征，17例有明显改善，2例轻度改善，2例无改善。25例肘管综合征中5例完全恢复，18例明显改善，2例未恢复。27例腕管综合征中11例症状完全消失，16例症状明显改善。11例腓总神经卡压征，6例明显改善，3例部分改善；2例未恢复。结论 小切口及利用显微外科技术作神经外膜松解术是治疗四肢神经卡压征的一种好方法。     

腓浅神经卡压综合征

目的：探讨腓浅神经卡压综合征的解剖学基础和手术方法。方法：对２例腓浅神经卡压综合征患者进行了手术治疗，并观测了６０侧成人腓骨下端的骨前嵴和３０侧尸体小腿标本。结论：“站立性”小腿、足背及踝前疼痛是腓浅神经卡压综合征的特征，是腓浅神经行至腓骨下端骨前嵴时遭受深筋膜或伸肌上支持带卡压所致。治疗方法是切开深筋膜或伸肌上支持带，将腓浅神经远离腓骨前嵴固定于皮下。     

显微外科手术治疗腓总神经卡压综合征26例

目的 评价应用显微外科手术治疗腓总神经卡压综合征的临床疗效. 方法 从2005年11月至201 1年12月,对腓总神经卡压综合征26例应用显微外科手术治疗,除全部行常规手术及神经外膜松解外,其中18例又进一步行神经束膜松解,术后辅以神经营养药物等治疗. 结果 术后随访时间为10个月～6年,平均3.5年.术前20例肌力下降的患者术后肌力恢复优良率为75.0％;术前感觉减退及消失者10例,术后感觉恢复率为80.0％;术前疼痛16例,术后缓解有效率为87.5％. 结论 应用显微外科手术行腓总神经松解治疗腓总神经卡压综合征较简便易行,其临床疗效可靠且副损伤小.     

双腓总神经急性卡压征1例

1　临床资料患者,女,26岁,农民,汉族。因双膝关节连续屈曲蹲位劳动12ｈ,出现双小腿麻木、足及足趾背伸障碍,逐渐加重,8天入院。体检:患者行走呈跨越步态,双小腿及足背外侧触觉、痛觉减退,双侧腓骨颈部Ｔｉｎｅｌ征阳性,双侧拇长伸肌、趾长伸肌、胫前肌、腓骨长短肌的肌力均为Ⅲ级,双侧屈趾肌及小腿三头肌的肌力正常。临床诊断:双腓总神经急性卡压征。手术探查发现,右腓总神经在腓管内有4ｃｍ长明显充血、水肿、灰暗无光泽、柔软性不良,左腓总神经在腓管内有3ｃｍ长轻度充血、水肿,伴行血管淤滞、扩张。为证明此病理改变的病因,模拟下蹲的姿…     

腓总神经嵌压综合征

报告腓总神经嵌压综合征９例，用保守疗法治疗３例，手术治疗６例，获满意疗效。该症的发生与腓总神经在窝至腓骨颈的解剖特点密切相关。主要病因为膝关节急剧屈曲下蹲位劳动使腓总神经反复损伤和局部赘生物压迫。临床表现为胫前肌、腓骨长肌、长伸肌、趾长伸肌等肌力减退或麻痹，小腿外侧及足背皮肤麻木或感觉缺失。电生理检查对诊断有一定价值。早期可保守治疗，３个月无效者，即应手术探查。局部赘生物嵌压者，应将其切除，进行彻底的神经松解术。     

显微外科技术治疗骨间后神经卡压综合征17例

目的探讨显微外科技术治疗骨间后神经卡压综合征的疗效.方法对17例骨间后神经卡压征患者采用显微外科技术进行神经减压松解术.结果术后平均随访8个月,前臂伸肌肌力及肌电图检查均恢复正常.结论显微外科技术是治疗骨间后神经卡压综合征的有效方法.     

腓总神经继发性卡压的治疗

目的　探讨坐骨神经损伤后腓总神经继发性卡压的发生机制、诊断及治疗。方法　对 5例坐骨神经损伤后患者的临床表现、腓管 Tinel征及治疗情况等进行综合分析 ,发现 5例患者均存在腓总神经继发性卡压 ,均行腓管切开减压松解。结果　术后随访 13～ 37个月 ,平均 2 5个月 ,4例足背伸肌力由术前 0～ 级恢复至 ～ 级 ,1例未恢复。结论　坐骨神经损伤后腓管处产生腓总神经继发性卡压 ,一旦诊断明确 ,须尽早行腓管切开减压 ,亦可在早期修复坐骨神经时行腓管松解术 ,预防继发性卡压发生     

15例骨间前神经卡压综合征诊断治疗

目的探讨骨间前神经卡压综合征的发病机制、临床特点和手术疗效。方法对1990-2001年收治的15例骨间前神经卡压综合征患者的病因、症状与体征、术中病理和处理方法进行回顾性分析。结果经手术证实所有患者骨间前神经受到卡压，行手术减压。术后随访5—24个月，13例拇指、食指末节屈曲功能已完全恢复。2例拇长屈肌、食指指深屈肌肌力Ⅳ级，基本恢复对指功能。结论骨间前神经卡压综合征以逐渐或突发性的拇指、食指屈曲无力和无感觉障碍为特征，诊断一经确立应及早手术治疗，彻底解除卡压因素。     

骨间背神经肌支损伤手术治疗15例

目的 探讨骨间背神经肌支损伤的手术治疗方法，提高该病的治疗水平。方法 对近8年来收治的15例骨间背神经肌支损伤病人手术治疗方法进行分析，1例行神经松解术，6例行静脉桥接术，2例行神经移植加小血管包裹术，其余6例行伸指和（或）伸拇功能重建术。结果 术后随访13例，随访半年～3年。13例主动伸指和（或）伸拇功能均恢复良好，术前功能障碍指伸指肌力均在Ⅲ级以上。结论 骨间背神经肌支损伤应依据损伤程度、损伤类型、损伤时间的不同采取不同的手术方法。     

Extensor hallucis longus innervation: an anatomic study

Thirty legs from skeletally mature embalmed cadavers were dissected to define the most common pattern and the variants of innervation of the extensor hallucis longus muscle and its clinical significance. Twenty-seven muscles had only one innervating branch (90%). Only three muscles had two innervating branches (10%). Twenty-one of the branches entered the muscles from the fibular side (63.6%), six entered the muscles from the tibial side (18.2%), and six entered the muscles from the anterior edge (18.2%). The branches innervating the extensor hallucis longus from the fibular side had a closer relation with the fibular periosteum than those entering the muscle from the tibial side or the anterior edge. The mean length of these branches between their points of origin and entry in the extensor hallucis longus was 5.0 +/- 1.5 cm. The high risk zone for the iatrogenic injury to the muscular branch of the extensor hallucis longus was located between 5.9 +/- 1.7 and 10.9 +/- 1.7 cm inferior to the most distal palpable point of the fibular head. The current study confirmed that the extensor hallucis longus was supplied mostly by one nerve that usually entered the muscle from the fibular side and had a close relation to the fibular periosteum in the dangerous zone.     

Palsy of the deep peroneal nerve after proximal tibial osteotomy. An anatomical study.

Iatrogenic, isolated weakness or paralysis of the extensor hallucis longus muscle is a common complication in patients who have had a proximal tibial and fibular osteotomy. To investigate why this complication occurs, we dissected the deep peroneal nerve and neighboring structures, such as the tibia and fibula and the muscles of the leg, in twenty-nine specimens from cadavera, paying special attention to the motor branches supplying the extensor hallucis longus. Of forty-six motor nerves that were identified, eight entered the muscle from the lateral side in an area seventy to 150 millimeters distal to the fibular head; all of them ran close to the fibular periosteum. We suggest that, in some patients, the nerve supply to the extensor hallucis longus is at high risk for injury during a tibial osteotomy because of the proximity of the bone to the motor branches.     

Possible injury to the branches of the peroneal nerve during fibular osteotomies

Conclusions The peroneal nerves and their blood supply are at risk during high tibial osteotomies. Fixation of nerves by fibrous tissues, compression by tendinous arcades of the peroneus longus tendon, and narrow passages for nerves crossing dense fibrous septa are all factors which favor the development of peroneal nerve lesions. Intraoperative soft tissue retraction and pull by retractors may damage nerves and vessels. The muscle branch for the extensor hallucis longus muscle is particularly at risk during the fibular osteotomy since it runs directly on the bone.     

The isolated loss of extension of the great toe following osteotomy of the fibula (author's transl)]

A peroneal nerve palsy can be observed following operative procedures or traumatic lesions of the lower leg. Primary damage of the nerve must be differentiated from the tibialis-anterior syndrome and the pseudo-paralysis. Following corrective osteotomies of the tibia with dissection of the fibula in the upper or medial third isolated lesions of the extensor hallucis longus muscle can be seen. Electromyographic and anatomical studies reveal that they may be caused by an isolated damage of the motor nerve fibres connecting the deep branch of the peroneal nerve with the extensor hallucis longus muscle lying very close to the fibula. Suggestions how to avoid this damage are made in the paper.     

Deep peroneal nerve palsy with isolated lateral compartment syndrome secondary to peroneus longus tear: a report of two cases and a review of the literature

Drop foot is typically caused by neurologic disease such as lumbar disc herniation, but we report two rare cases of deep peroneal nerve palsy with isolated lateral compartment syndrome secondary to peroneus longus tears. Both patients developed mild pain in the lower legs while playing sport, and were aware of drop foot. As compartment pressures were elevated, fasciotomy was performed immediately, and the tendon of the peroneus longus was completely detached from its proximal origin. The patients were able to return their original sports after 3 months, and clinical examination revealed no hypesthesia or muscle weakness in the deep peroneal nerve area at the time of last follow-up. The common peroneal nerve pierced the deep fascia and lay over the fibular neck, which formed the floor of a short tunnel (the so-called fibular tunnel), then passed the lateral compartment just behind the peroneus longus. The characteristic anatomical situation between the fibular tunnel and peroneus longus might have caused deep peroneal nerve palsy in these two cases after hematoma adjacent to the fibular tunnel increased lateral compartment pressure.     

The relationship between the deep fibular nerve and the dorsalis pedis artery and its surgical importance

The aim of this study was to demonstrate the relationship between the deep fibular nerve and the dorsalis pedis artery to provide useful anatomical knowledge for safe surgical approaches in plastic surgery. The dissection of 30 cadaver lower limbs was undertaken to describe the relationship of the deep fibular nerve to the dorsalis pedis artery in the anterior tarsal tunnel and on the dorsum of the foot. The anterior tarsal tunnel is a flattened space between the inferior extensor retinaculum and the fascia overlying the talus and navicular. The deep fibular nerve and its branches pass longitudinally through this fibro-osseous tunnel, deep to the tendons of the extensor hallucis longus and extensor digitorum longus. Four distinct relationships of the deep fibular nerve to the dorsalis pedis artery were determined. The dorsalis pedis neurovascular island flap contains both the dorsalis pedis artery and the deep fibular nerve. Because the design of a neurovascular free flap requires detailed knowledge of the nerve and vascular supply, the data presented here are intended to help surgeons during surgical approaches to the foot and ankle.     

The Use of Ultrasonography to Identify the Intersection of the Dorsomedial Cutaneous Nerve of the Hallux and the Extensor Hallucis Longus Tendon: A Cadaveric Study

Terminal branches of the superficial fibular nerve are at risk of iatrogenic damage during foot surgery, including hallux valgus rigidus correction, bunionectomy, cheilectomy, and extensor hallucis longus tendon transfer. One terminal branch, the dorsomedial cutaneous nerve of the hallux, is particularly at risk of injury at its intersection with the extensor hallucis longus tendon. Iatrogenic injuries of the dorsomedial cutaneous nerve of the hallux can result in sensory loss, neuroma formation, and/or debilitating causalgia. Therefore, preoperative identification of the nerve is of great clinical importance. The present study used ultrasonography to identify the intersection between the dorsomedial cutaneous nerve of the hallux and the extensor hallucis longus tendon in cadavers. On ultrasound identification of the intersection, dissection was performed to assess the accuracy of the ultrasound screening. The method successfully pinpointed the nerve in 21 of 28 feet (75%). The sensitivity, positive likelihood ratio, and positive and negative predictive values of ultrasound identification of the junction of the dorsomedial cutaneous nerve and the extensor hallucis longus tendon were 75%, 75%, 100%, and 0%, respectively. We have described an ultrasound protocol that allows for the preoperative identification of the dorsomedial cutaneous nerve of the hallux as it crosses the extensor hallucis longus tendon. The technique could potentially be used to prevent the debilitating iatrogenic injuries known to occur in association with many common foot surgeries.     

Partially irreversible paresis of the deep peroneal nerve caused by osteocartilaginous exostosis of the fibula without affecting the tibialis anterior muscle

Dysfunction of the lower limb's muscles can cause severe impairment and immobilisation of the patient. As one of the leg's major motor and sensory nerves, the deep peroneal nerve (synonym: deep fibular nerve) plays a very important role in muscle innervation in the lower extremities. We report the case of a 19-year-old female patient, who suffered from a brace-like exostosis 6-cm underneath her left fibular head causing a partially irreversible paresis of her deep peroneal nerve. This nerve damage resulted in complete atrophy of her extensor digitorum longus and extensor hallucis longus muscle, and in painful sensory disturbance at her left shin and first web space. The tibialis anterior muscle stayed intact because its motor branch left the deep peroneal nerve proximal to the nerve lesion. Diagnosis was first verified 6 years after the onset of symptoms by a magnetic resonance imaging (MRI) scan of her complete left lower leg. Subsequently, the patient was operated on in our clinic, where a neurolysis was performed and the 4-cm-long osteocartilaginous exostosis was removed. Paralysis was already irreversible but sensibility returned completely after neurolysis. The presented case shows that an osteocartilaginous exostosis can be the cause for partial deep peroneal nerve paresis. If this disorder is diagnosed at an early stage, nerve damage is reversible. Typical for an exostosis is its first appearance during the juvenile growth phase.     

Compression neuropathy of common peroneal nerve caused by an extraneural ganglion: a report of two cases

Peroneal nerve entrapment is most common in the popliteal fossa, but is rarely caused by a ganglion. Although ganglionic cysts are very common lesions, they seldom cause serious complications. Ganglionic cysts developing in the sheath of a peripheral nerve or joint capsule may cause compression neuropathy. We report on two cases of compression neuropathy of the common peroneal nerve caused by an extraneural ganglion and its evaluation with magnetic resonance imaging (MRI) and ultrasonography. The differential diagnosis should involve L5 root pathology, a posttraumatic intraneural hemorrhage, a nerve compression near the tendinous arch located at the fibular insertion of the peroneal longus muscle, and a nerve-sheath tumor. The combination of MRI and ultrasonography is useful for the accurate diagnosis of this condition, and it should be treated by microsurgical exploration as soon as possible.