Case Report

Common Peroneal Nerve Entrapment Complicated with Fracture of Fibular Neck Without Displacement: A Case of Delayed Treatment

by Hongtao Xiong*

Department of Hand, and Microvascular Surgery, Shenzhen People’s Hospital, Guangdong, China

*Corresponding author: Hongtao Xiong, Department of Hand, and Microvascular Surgery, Shenzhen People’s Hospital, Guangdong, China.

Received Date: 16 November 2023

Accepted Date: 20 November 2023

Published Date: 23 November 2023

Citation: Xiong H (2023) Common Peroneal Nerve Entrapment Complicated with Fracture of Fibular Neck Without Displacement: A Case of Delayed Treatment. Ann Case Report 8: 1519. https://doi.org/10.29011/2574-7754.101519

Abstract

Background: Compression of peroneal nerve is a common complication after fibular neck fracture. The peroneal nerve entrapment symptoms are easy to find, but sometimes the indications for surgical treatment are difficult to be recognized. It results in delayed surgical release treatment and reduced recovery effect after long conservative treatment and observation time for some patients. Material and Methods: A case and treatment of common peroneal nerve paralysis for 6 months, which was caused by a fracture of the fibular neck without displacement, was reported. The fiber sheath of patient was completely cut, and the common peroneal nerve was completely released. Results: One year later, the extensor muscle strength of the ankle joint and 2-5 toes was restored to 4 / 5, and the extensor muscle strength of the toes was restored to 4 / 5 grade. The clinical symptoms, diagnosis, differential diagnosis of imaging methods, neurology, pathology and more extensive surgical and non-surgical treatment were discussed. Conclusions: The sources of common fibular compression neuropathy were clarified. It is important to diagnose and treat in time for the better outcome.

Keywords: Fibular Neck; Fracture; Common Peroneal Nerve Compression; Common Peroneal Nerve Releases; Delayed Diagnosis and Treatment; Case Report.

Introduction

Compression of the common peroneal nerve (CPN) is the most common compression neuropathy of lower limbs. The causes can be divided into traumatic and non-traumatic, which includes long-term external force compression, nerve contusion caused by direct impact of the fibular neck, open nerve cutting injury, nerve strain caused by knee dislocation, proximal fibular fracture, weight loss, etc. [1,2]. The diagnosis is usually made by symptoms and physical examination of decreased strength, sensory changes and gait abnormalities. The foot ptosis, lower limb pain, or lower limb numbness are the representative symptoms for the patients with compression of the common peroneal nerve. Motor nerve conduction, electromyography and diagnostic nerve block are also valuable for diagnosis and prognosis. The symptoms of common peroneal neuropathy need to be distinguished from the compression of superficial peroneal nerve (SPN) or deep peroneal nerve (DPN). Accurate and timely diagnosis of any peroneal neuropathy is very important to avoid the progression of nerve injury and permanent nerve injury. Due to the lack of large-scale studies to report outcomes on various treatments, it is difficult to accurately perform the clinical evaluation of common peroneal nerve compression therapy [3,4].

In this report, a case and treatment of the compression of common peroneal nerve without displacement of the fractured fibular neck, which resulted in nerve dysfunction, was introduced. Because the operation was too late, ankle and toe paralysis and sensory function of the dorsum of the foot were not well recovered. The roles of multidisciplinary teams in the evaluation, treatment and management of patients with such injury were described. The patient agreed to submit this case for publication.

Case Report

The middle and upper tibia and fibular neck of the left leg of 41-year old male were fractured 6 months ago. X-ray examination showed that the middle and upper tibia were comminuted and displaced, and the fibular neck fracture was not displaced. The dysfunction was found at left ankle joint, toe dorsiflexion, and left foot dorsiflexion. On the 11th day after the injuries, open reduction of tibia and internal fixation of bone plate were performed in the local hospital. After 6 months of conservative treatment, the motion of left ankle joint and toe dorsiflexion and left foot dorsiflexion was unsatisfactory. Therefore, he was admitted our hospital for " left foot dorsum extension movement and foot dorsum sensory dysfunction after the operation for 6 months". The admission physical examination showed that the anterolateral arc-shaped surgical scar at the middle and upper leg was about 20cm long, extending from the outer side of the tibia anterior crest to the upper part of the fibular head. The extensor muscle strength of the ankle joint was 3 / 5 +, the extensor muscle strength of the toe was 3 / 5, the extensor muscle strength of the toe was 3 / 5 +, and the sensory function of the foot was decreased. The plantar sensory function was normal, and the plantar flexor strength of each toe and ankle joint was grade 5 / 5. Nerve conduction studies confirmed that the latency of the common peroneal nerve on the left side of the knee joint increased and the amplitude decreased, while EMG showed denervation of the tibialis anterior muscle and extensor digitorum brevis. The common peroneal nerve entrapment was diagnosed.

To avoid further loss of limb function, the patient was advised to perform surgical exploration. During the operation, the common peroneal nerve at the peroneal neck was routinely taken to explore the common peroneal nerve. No apparent abnormality in the common peroneal nerve at the peroneal neck was observed. The tunnel wall around the nerve was smooth, there was no obvious scar, the nerve compression was not obvious, and the nerve branch continuity of the peroneal long and short muscles was good. During the operation, the electrical stimulation of the common peroneal nerve, and the obvious contraction of the peroneal long and short muscles could be seen, but the back extension of the ankle joint was not obvious. The incision was extended to further explore the common peroneal nerve upward. It was observed that the common peroneal nerve behind the fibular head was obviously enlarged, and the common peroneal nerve was relatively thin at the fibular neck, with a dark color. The cause of the disease was the common peroneal nerve entrapment. The adventitia of the common peroneal nerve was released under the microscope and the intraoperative electrical stimulation was performed. After hemostasis, the wound was rinsed and triamcinolone acetonide was applied locally to prevent adhesion. The drainage sheet was left in the wound for 24 hours. The wound was covered with sterile dressings with the application of bandages. Finally, the ankle was fixed at 90° angle with plaster splint for 3 weeks.