Intermediate Dorsal Cutaneous Nerve Research Articles

Ultrasound-guided injection of the ankle joint: cadaveric investigation of the anterolateral approach.

Injection of the tibiotalar (TT) joint is commonly performed in clinical practice under ultrasound (US) guidance using an anteromedial approach. However, in some patients, this approach may be technically challenging due to post-traumatic and/or degenerative bony changes. Therefore, the aim of this cadaveric investigation was to demonstrate the feasibility of the ultrasound-guided (USG) injection of the ankle joint via the anterolateral sulcus (ALS) by confirming the dye placement/distribution inside the articular space. Likewise, the safety of the procedure has also been evaluated by measuring the distance between the needle and the intermediate dorsal cutaneous nerve of the foot. A descriptive laboratory study with eight embalmed cadaveric ankles using the Fix for Life (F4L) method was performed at the setting of an academic institution. The interventional technique and the related anatomical findings were illustrated. During the injection, the needle was advanced into the TT joint through the ALS under US guidance, i.e., in-plane anterior-to-posterior approach. With the objective to confirm its correct placement, the needle was kept in situ and-to demonstrate the location of the dye inside the articular space-all eight ankles were injected with 3 mL of green color dye. Thereafter, a layer-by-layer anatomical dissection was performed on all four cadavers. The position of the needle's tip within the ALS was confirmed in all specimens. Accurate placement of the dye inside the articular space of the ankle was confirmed in seven of the eight cadaveric ankles, with 87.5% of accuracy. Herewith, unintentional spilling of the dye within the superficial soft tissues was reported in two of the eight ankles (25.0%). The mean distance between the needle and the intermediate dorsal cutaneous nerve of the foot, measured in all eight procedures, was 3 cm. USG injection of the ALS using the in-plane, anterior-to-posterior approach can accurately place the injectate inside the articular space. This cadaveric investigation described the accuracy and potential pitfalls of USG injection of the ankle via the anterolateral approach which represents an alternative technique in patients with reduced accessibility of the anteromedial recess due to degenerative and/or post-traumatic bony changes.

Anatomical Variations in the Course and Level of Termination of Superficial Peroneal Nerve- A Cadaveric Study

Introduction: Several variations in the course and branching pattern of the Superficial Peroneal Nerve (SPN) have been reported. Knowledge of the different course of SPN is essential in reducing the risk of iatrogenic injury during the orthopaedic foot and ankle surgery and various other procedures. Aim: To observe any variations in the course, and level of termination of SPN. Materials and Methods: This descriptive analytical study was conducted on 50 lower limb specimens in the Department of Anatomy, Bangalore Medical College and Research Institute Bengaluru from January 2013 to January 2016. Dissection kit was used for dissection, digital camera was used for photography of specimens, measuring tape was used to measure the distance at which the SPN became cutaneous with respect to the tip of lateral malleolus and the distance at which SPN terminated into medial and Intermediate Dorsal Cutaneous Nerve (IDCN) with reference to the tip of lateral malleolus. Descriptive statistics was used and results were expressed as Mean±SD. Results: It was observed that the distance at which SPN became cutaneous with respect to tip of lateral malleolus was 10±2.82 cm. The level of termination of SPN into Medial Dorsal Cutaneous Nerve (MDCN) and IDCN with reference to tip of lateral malleolus was 4.7±2.08 cm. In 5 (10%) of 50 specimens the SPN terminated at a higher level before piercing the deep fascia. Out of these 5 specimens, it was observed that in one specimen the SPN terminated above the head of fibula before piercing Peroneus Longus (PL) muscle. In another specimen, the SPN terminated near the head of fibula before piercing PL muscle. In one of the specimens SPN terminated near head of fibula after piercing PL, in two specimens SPN terminated in upper third of the leg after piercing PL muscle and their terminal branches pierced the deep fascia and emerged out at different level with respect to tip of lateral malleolus. Conclusion: SPN became cutaneous and terminated in the distal third of the leg in most cases. This knowledge is very helpful to surgeons and orthopaedists in performing fasciotomy, and ankle arthroscopy to prevent iatrogenic injury to the nerve.

Variations in Innervation Pattern to Dorsum of Foot by Medial Dorsal Cutaneous Nerve, Intermediate Dorsal Cutaneous Nerve, Lateral Dorsal Cutaneous Nerve with Surgical and Clinical Correlations: A Cadaveric Dissection Based Study

The complete reconstruction of any soft tissue defect includes even the sensory recovery which is very significant aspect pertaining to prognosis. Superficial nerves in the vicinity of the vascular axis can be considered as vascular relays and neuroskin grafts can be constructed on them. Variations in innervation to various part of the dorsum of the foot by this nerve should be kept in mind while making these grafts. Authors dissected 50 formalinized cadaveric feet and studied normal anatomy and variations in origin, course, branching pattern, communications, and any other variations in medial, intermediate and lateral dorsal cutaneous nerve. The intermediate dorsal cutaneous nerve was innervating larger area of the skin around 3rd and 4th web spaces in 60% of cadaveric feet. The 2nd web space was innervated by medial dorsal cutaneous nerve in 92% of cadaveric feet. In 52% of cadaveric feet communicating branches were found between intermediate dorsal cutaneous nerve and lateral dorsal cutaneous nerve. In 63% cadaveric feet communicating branches were found between medial dorsal cutaneous nerve and branch of deep peroneal nerve to 2nd web space. The mean distance between lateral malleolus and intermediate dorsal cutaneous nerve was 4.05cm. These all observations can provide anatomical basis at the time of preparing medial dorsal cutaneous nerve flaps and intermediate dorsal cutaneous nerve flaps and also can minimize morbidity at donor site. KEY WORDS: Medial Dorsal Cutaneous Nerve, Intermediate Dorsal Cutaneous Nerve, Lateral Dorsal Cutaneous Nerve, Medial Dorsal Cutaneous Nerve Flap, Intermediate Dorsal Cutaneous Nerve Flap, Soft Tissue Defects, Open Reduction And Internal Fixation Of Fibula, Arthroscopy, Local Anesthetic Block, First Dorsal Metatarsal Artery Flap, Defects In Distal Dorsalis Pedis, Compression And Entrapment Neuropathies.

A combined functional dorsal nerve model of the foot.

The nerves in the skin surface of the foot are comprised of unmyelinated smaller somatic nerves and larger myelinated sensory nerves. Current diagnostic methods are unable to evaluate combined nerve conduction velocity (NCV) from both unmyelinated smaller somatic nerve (USSN) and myelinated larger nerves (MLN) respectively. Computational models may provide an alternative tool to determine the NCV of the combined nerve. Therefore, a combined functional dorsal nerve model (CFDNM) of the various dorsal nerves along with its associated nerve ending of the human foot is proposed and constructed. The combined dorsal nerve model consists of synthetic USSN (SUSSN) and dorsal MLN of the foot. The unmyelinated as well as myelinated electrophysiological nerve models were used to simulate selected SUSSN and MLN of the foot by injecting an external stimulus at the most distal part of SUSSN of the foot through the use of bidomain model. Results from our work demonstrated that the action potential propagated from the most distal part to proximal part of distinct dorsal nerves of the foot, e.g., the simulated NCV of the combined intermediate dorsal cutaneous nerve (IDCN) of the foot was 28.4 m s-1. The CFDNM will provide a vital tool for diagnosis initially small fibre neuropathy (SFN) by computing NCV in the prospective studies.

Risk of Injury to the LDCN and IACN During Surgical Approaches to the Foot and Ankle: an Anatomical Study using 3-Tesla Magnetic Resonance Imaging

Category:Ankle; OtherIntroduction/Purpose:The dorsomedial branch of the lateral dorsal cutaneous nerve (dmLDCN) and anastomotic branch to the intermediate dorsal cutaneous nerve (AICN) are at risk during foot and ankle surgery. Prior studies of the distal sural nerve on cadaveric specimens are limited by small sample size.1-7 We sought to use high-field 3-tesla (3T) magnetic resonance imaging (MRI) to examine a significantly larger cohort and obtain a more representative sample of the course of the dmLDCN and AICN. A more generalizable understanding of the course and position of these structures will aid surgeons intraoperatively in avoiding iatrogenic injury when performing the dorsomedial approach to the fifth metatarsal, as well as the sinus tarsi and extended sinus tarsi approaches for calcaneal fractures and subtalar/calcaneocuboid fusions.Methods:High-field 3T MRI studies performed between January 2015 to January 2020 were reviewed. Three blinded reviewers at a single academic center measured the coronal distances of dmLDCN and AICN from the fifth metatarsal styloid (5MS). Intraclass correlation coefficients (ICC) were calculated to assess reviewer reliability. We analyzed the upper and lower quartile ranges to evaluate the risk of iatrogenic nerve injury with standard surgical approaches.Results:A total of 125 foot and ankle 3T MRIs were measured. Intraclass correlation coefficient was excellent at 0.87 for dmLDCN to 5MS and 0.88 for AICN to 5MS. 1st and 4th quartile range for the dmLDCN to the 5MS was 0.5-0.7 cm and 0.9-1.4 cm, respectively. 1st and 4th quartile range for the AICN to the 5MS was 1.6-1.9 cm and 2.3-3.2 cm respectively. The AICN was identified in 47.2% of the images.Conclusion:The dmLDCN, AICN, and SN are vulnerable to iatrogenic injury during surgical approaches to the fifth metatarsal and calcaneus. Our 1st quartile range for the dmLDCN to the 5MS of 0.5-0.7 cm suggests that nearly 25% of our values measured by 3T MRI were lower than the reported range of 0.7-1.2 cm by Fansa, suggesting iatrogenic injury to the dmLDCN with the 'high and inside approach' to the fifth metatarsal may be higher than previously thought. The 4th quartile range of the AICN's distance from the 5MS of 2.3-3.2cm places it at risk with the sinus tarsi approach.

Lateral Dorsal Cutaneous Nerve and Anastomotic Branch to the Intermediate Dorsal Cutaneous Nerve: A Review of Cadaveric Data and Comparison with 3 Tesla MRI

Category:Other; HindfootIntroduction/Purpose:The lateral dorsal cutaneous nerve (LDCN) and anastomotic branch to the intermediate dorsal cutaneous nerve (AICN) can be injured during foot and ankle surgery. Cadaveric specimen studies are limited by small sample size.1-11 We sought to use high-field 3-tesla (3T) magnetic resonance imaging (MRI) to examine a significantly larger cohort and obtain a more representative sample of the course of the LDCN and AICN. A more generalizable understanding of the course and position of these structures will aid surgeons intraoperatively in avoiding iatrogenic injury when performing the sinus tarsi approach, as well as during percutaneous intramedullary fixation of the 5th metatarsal.Methods:High-field 3T MRI studies performed between January 2015 to January 2020 were reviewed. Three blinded reviewers at a single academic center measured the coronal distances of LDCN and AICN from the fifth metatarsal styloid (5MS). Intraclass correlation coefficients (ICC) were calculated to assess reviewer reliability. Foot and ankle MRIs with major structural abnormalities, such as tumor or the presence of hardware, were excluded.Results:A total of 125 foot and ankle 3T MRIs were identified. Intraclass correlation coefficient was excellent at 0.87 for LDCN to 5MS and 0.88 for AICN to 5MS. The mean distance of the LDCN to the 5MS was 0.8 cm (range 0.3-1.4 cm, CI 0.8-0.8 cm) and that from the AICN to the 5MS was 2.1 cm (range 1.6-3.2 cm, CI 2.0-2.2 cm. Height had no significant correlation with the nerves' distance from bony landmarks with r values of 0.14 and 0.29 for the LDCN and AICN, respectively. Similarly, we did not find BMI to significantly correlate, with r values of 0.10 and 0.30 for the LDCN and AICN, respectively.Conclusion:Our study demonstrated the LDCN and AICN can be found on average 0.8 cm and 2.1 cm, respectively, above the 5MS with no clear association to patient height or BMI. Literature studying the range of distances the LDCN is found from the 5MS is scarce, but one study noted the range to be 0.7-1.2 cm, which is significantly smaller than our range of 0.3-1.4 cm.3 To our knowledge, our study is first to note the range of distances the AICN can be found from the 5MS, which is 1.6-3.2 cm.

Minimally Invasive Surgery for Correction of Adult Acquired Flat Foot Deformity: An Anatomic Study

Category:Midfoot/Forefoot; HindfootIntroduction/Purpose:Adult acquired flatfoot deformity (AAFD) is a complex and chronic debilitating condition characterized by a decrease in the medial arch height and, in advanced stages, a decrease in the talonavicular coverage angle as the forefoot drifts into pronation and abduction. Operative treatment of stage II deformity has changed significantly over the past few decades. Joint sparing procedures which aim to realign the hindfoot and augment the diseased tibialis posterior tendon with the flexor digitorum longus transfer are commonly performed. The introduction of minimally invasive surgery (MIS) has been associated with smaller incisions, less blood loss, and quicker recovery times. The purpose of this study was to qualitatively and quantitatively observe the tendinous and neurovascular structures at risk with MIS AAFD osteotomy procedures in cadaveric feet.Methods:MIS technique was used to perform medial displacement calcaneal, Evans, and Cotton osteotomies on nine cadaveric feet under fluoroscopic guidance. The sural nerve, superficial peroneal nerve and its branches, deep peroneal nerve, dorsalis pedis artery, saphenous vein, and peroneal and extensor hallucis longus tendons were carefully dissected from each cadaveric foot and evaluated for injuries following the MIS osteotomy cuts. The distance from the osteotomy cuts and these anatomic structures were measured and recorded.Results:On average, the sural nerve was 8.4 mm and 9 mm from the calcaneal and Evans osteotomy sites, respectively. The intermediate dorsal cutaneous nerve was on average 68.3 mm and 41.1 mm from the calcaneal and Evans osteotomy sites, respectively. The peroneal tendons were on average 16.7 mm and 0 mm from the calcaneal and Evans osteotomy sites, respectively. The extensor hallucis was an average of 1 mm from the Cotton osteotomy site. There was a partial tear injury to the peroneus brevis in four of the cadaveric specimens at the Evans osteotomy site without complete laceration. There was no injury to the sural nerve, superficial peroneal nerve and its branches, saphenous vein, deep peroneal nerve, dorsalis pedis artery, or extensor hallucis longus tendon.Conclusion:Tendinous and neurovascular structures are at risk with MIS AAFD osteotomy procedures. Care should be taken with soft tissue handling and blunt dissection to decrease iatrogenic injuries to these structures. Specifically, extra care and recognition of the peroneal tendons during the Evans osteotomy may prevent damage, as this structure was at greatest risk among the three osteotomy cuts. Future research studies evaluating this technique and the functional outcomes in patients in a clinical setting is warranted. Surgical technique studies are underway to implement smaller, yet appropriate bone grafts through mini incisions.

A Technique for the Reduction of Complications Associated With Anterior Portal Placement During Ankle Arthroscopy Using a Peripheral Vein Illumination Device

Ankle arthroscopy is a minimally invasive technique for ankle joint treatment. However, injury to the intermediate dorsal cutaneous nerve (IDCN) and the medial dorsal cutaneous nerve (MDCN) is a common complication during anterior portal placement. To prevent injuries, methods such as palpating the nerves topographically and marking the nerves by transilluminating the skin with an arthroscope have been proposed. Easier and more definitive methods of identifying the IDCN and MDCN should result in a reduction of complications. Recently, a vein imaging system was developed that projects images of subcutaneous vasculature directly onto the skin with the use of near-infrared (NIR) light. Because anatomic studies have shown that superficial veins accompany the IDCN and MDCN, protecting the subcutaneous veins could lower the risk of nerve injury. We introduce our technique for the creation of an ankle arthroscopic portal using an NIR imaging system, which displays the vein image on the skin, to prevent injury to the superficial veins and, consequently, reduce IDCN and MDCN injuries. This is the first technical report on the prevention of vein and nerve injuries using an NIR imaging system. Our technique for avoiding vein injury using a peripheral vein illumination device during anterior portal placement in ankle arthroscopy could lower the risk of complications.

Sonography-guided recording for superficial peroneal sensory nerve conduction study.

We sought to establish the optimal recording position for antidromic conduction of the superficial peroneal nerve (SPN) by using ultrasonography (USG). The sensory nerve action potentials (SNAPs) of the intermediate dorsal cutaneous nerve (IDCN) and medial dorsal cutaneous nerve (MDCN) in 64 limbs of 32 healthy participants were recorded (nerve conduction study [NCS]-1). Both nerves were identified by using USG, and the SNAPs were obtained from the USG-guided repositioned electrodes (NCS-2). The IDCN and MDCN were located at 29.3% ± 5.1% and 43.9% ± 4.9% of the intermalleolar distance from the lateral malleolus, respectively. Significantly greater amplitude was shown for SNAPs of both nerves in NCS-2 versus NCS-1. The optimal recording position is likely to be lateral, one-third from the lateral malleolus for the IDCN, and just lateral to the midpoint of the intermalleolar line for the MDCN. When the SPN response is unexpectedly attenuated, USG-guided repositioning of the electrodes should be considered. Muscle Nerve 57: 628-633, 2018.

X-shaped inferior extensor retinaculum and its doubtful use in the Bröstrom-Gould procedure.

The inferior extensor retinaculum (IER) is an aponeurotic structure located in the anterior aspect of the ankle. According to the literature, it can be used to reinforce a repair of the anterior talofibular ligament in ankle instability. Despite its usual description as an Y-shaped structure, it is still unclear which part of the retinaculum is used for this purpose, or if it is instead the crural fascia that is being used. The purpose of this study is to define the anatomical characteristics of the IER to better understand its role in the Broström-Gould procedure. Twenty-one ankles were dissected. The morphology of the IER and its relationship with neighbouring structures were recorded. Seventeen (81%) of the IER in this study had an X-shaped morphology, with the presence of an additional oblique superolateral band. This band, by far the thinnest of the retinaculum, is supposed to be used to reinforce the repair of the anterior talofibular ligament. The intermediate dorsal cutaneous nerve (lateral branch of the superficial peroneal nerve) was found to cross the retinaculum in all cases. The IER is most commonly seen as an X-shaped structure, but the fact that the oblique superolateral band is a thin band of tissue probably indicates that it may not add significant strength to ankle stability. Furthermore, the close relationship of the retinaculum with the superficial peroneal nerve is another factor to consider before deciding to perform a Broström-Gould procedure. These anatomical findings advise against the use of the Gould augmentation.

Variations in the distal branches of the superficial fibular sensory nerve.

We evaluated anatomic variations of distal branches of the superficial fibular sensory nerve electrophysiologically. Orthodromic nerve conduction studies (NCS) of the first and third branches (M-I, M-III) of the medial dorsal cutaneous nerve and the fourth and fifth branches (I-IV, I-V) of the intermediate dorsal cutaneous nerve (IDCN) were performed. To find anomalous innervations from the dorsal sural nerve (DSN) in the IDCN territory, NCS of the fourth and fifth branches (S-IV, S-V) of the DSN were also performed. All sensory nerve action potentials (SNAPs) of M-I and M-III could be obtained bilaterally from 31 healthy Japanese volunteers. SNAPs of I-IV and I-V were recordable in 85.5% and 43.5% of feet, respectively. Anomalous innervations from the DSN were confirmed in 71.0% of S-IV and 93.5% of S-V. These results suggest that anatomical variations in the IDCN territory are very frequent in Japanese subjects. Muscle Nerve 55: 74-76, 2017.

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.

Correlation Between Visual Inspection and Ultrasonography to Identify the Distal Branches of the Superficial Peroneal Nerve: A Cadaveric Study

The anatomy of the superficial peroneal nerve (SPN) and, more precisely, of the distal branches of the SPN at the ankle has attracted interest owing to the possibility of injury when performing ankle arthroscopy. The anterolateral portal is one of the most commonly used portals in ankle arthroscopy, and the intermediate dorsal cutaneous nerve can easily be injured during portal placement. The purpose of the present study was to assess whether visual inspection and palpation of the cutaneous nerves at the ankle differed from examination with ultrasonography and whether the 2 examination techniques correlated with the anatomic location of the SPN, which was verified by cadaver dissection. First, visual examination and palpation was performed to identify the SPN, after which 12 cadaver legs from separate specimens were examined with ultrasonography to mark the course of the SPN. We then measured the distance between the nerve as identified with gross visualization/palpation and ultrasound examination, and compared these with the precise location determined by anatomic dissection. The use of ultrasonography to determine the course of the SPN was good or excellent in 11 of the 12 legs (91.7%) studied. In contrast, gross visualization/palpation was good or excellent in 4 legs (33.3%). Excellent agreement was observed between the ultrasound markings and the anatomic dissection results. However, the visual examination poorly identified the course and the anatomic variations of the nerve branches evidenced in the anatomic dissection. From these findings in cadaver specimens, ultrasound identification of the SPN and its branches is likely preferable to gross visualization/palpation before placement of the anterolateral arthroscopic portal to the ankle.

Determination and classification of cutaneous innervation of the dorsum of the foot in foetal cadavers.

The aim of this study is to determine cutaneous innervation of the dorsum of the foot on foetal cadavers. In this study. 200 limbs from 100 embalmed foetuses (54 males and 46 females) were studied in Anatomy Laboratory. Contributions of medial, lateral and intermediate dorsal cutaneous nerves (MDCN, LDCN and IDCN) of the foot were identified. Cutaneous innervation of the dorsum of the foot was classified into five types. Type I (75%) where MDCN innervated medial border of the foot and second interdigital cleft; IDCN innervated third, fourth and fifth interdigital clefts; and LDCN innervated the lateral border of the foot. Type II (21%) where MDCN innervated medial border of the foot, second and third interdigital clefts; IDCN innervated fourth and fifth interdigital clefts; and LDCN innervated the lateral border of the foot. Type III (1.5%) where saphenous nerve innervated medial border of the foot; MDCN innervated second and third interdigital clefts; IDCN innervated fourth and fifth interdigital clefts; and LDCN innervated the lateral border of the foot. Type IV (1.5%) was similar to type I, with an extra connection between the MDCN and IDCN on the dorsum of the foot. Type V (1%) where superficial fibular nerve innervated medial border of the foot, and second, third and fourth interdigital clefts; and sural nerve innervated fifth interdigital cleft and lateral border of the foot. The present study provides a new classification for the cutaneous innervation of the dorsum of the foot.

Ultrasound Visualization of the Superficial Peroneal Nerve in the Mid-calf

THE superficial peroneal nerve (SPN) arises from the common peroneal nerve at the level of the fibular neck and descends in the lateral compartment of the leg. In the distal half of the leg, the SPN is sandwiched between peroneus brevis and the intermuscular septum that separates the anterior and lateral compartments of the leg, and gradually ascends into a superficial location before eventually piercing the crural fascia.1,2 Here the SPN divides into medial and intermediate dorsal cutaneous nerves, which travel subcutaneously to supply the dorsum of the foot.3The SPN is traditionally blocked by “blind” subcutaneous infiltration of local anesthetic across the dorsum of the foot at the intermalleolar line. The SPN may, however, be reliably located and blocked using ultrasound by placing a high-frequency (10–15 MHz) linear-array transducer transversely across the lateral aspect of the leg midway between the fibular head and lateral malleolus. The chief landmark is the fibula, which in cross-section casts an acoustic shadow with a peaked appearance. The “peak” of this shadow points toward the intermuscular septum (IMS) and the SPN. The nerve is visible as a hyper- or hypoechoic structure lying between peroneus brevis (PB) and extensor digitorum longus (EDL) just deep to the crural fascia (dotted arrows, fig. A). The identity of the SPN can be confirmed by tracing it distally toward the ankle, and observing the nerve rise through the crural fascia into a subcutaneous location (fig. B). The nerve may also widen, reflecting its bifurcation into its terminal branches.

Electrophysiological Contribution of Both Sensory Branches of the Superficial Peroneal Nerve in the Diagnosis of Peripheral Neuropathy

ABSTRACT.The aim of this study is to evaluate the simultaneous recording of the medial dorsal cutaneous nerve (MDCN) and the intermediate dorsal cutaneous nerve (IDCN) in the investigation of peripheral neuropathy. We obtained MDCN and IDCN recordings in 35 patients with peripheral neuropathy and in 41 healthy subjects to determine the specificity of the sensory nerve action potential (SNAP) amplitude of each branch separately and of both simultaneously by using the maximal amplitude of either branch. The patients with peripheral neuropathy had low MDCN and IDCN SNAP amplitude in 60% and 14.3% respectively. Though, when recording both MDCN and IDCN simultaneously, the maximum peroneal SNAP amplitude was abnormally low in 68.6%. All the healthy individuals had normal IDCN SNAP amplitude; whereas in 9.7% the MDCN SNAP amplitude was lower than normal. In case of simultaneous recording of both branches the maximum SNAP amplitude was normal in all healthy subjects. Conclusively, the simultaneous amplitude recording of the terminal sensory peroneal branches can better detect abnormal responses in patients with peripheral neuropathy.

Lateral Leg Compartment Syndrome Caused by Ill-fitting Compression Stocking Placed for Deep Vein Thrombosis Prophylaxis During Surgery: A Case Report

Isolated lateral leg compartment syndrome is a relatively rare event, with potentially devastating consequences. We present a case of a 44-year-old man with isolated lateral leg compartment syndrome caused by a compression stocking used for deep vein thrombosis prophylaxis during surgery. It was found to be excessively tight around the patient’s proximal calf postoperatively. He underwent lateral leg compartment fasciotomy and delayed wound closure with a split-thickness skin graft. At the 7-month follow-up visit, he had returned to full activity, had no muscle deficits, and had numbness in the distribution of the intermediate dorsal cutaneous nerve.

Nerve Conduction Study of the Superficial Peroneal Sensory Distal Branches in Koreans

ObjectiveTo perform nerve conduction studies of the four branches of the superficial peroneal nerves to determine normal values and anatomic variations in Koreans.MethodAntidromic sensory nerve conduction studies of the four distal branches were performed on 70 healthy subjects (100 feet). We applied electrical stimulation at the midpoint of medial and lateral malleoli for the medial dorsal cutaneous nerve (MDCN), and at the lateral 1/4 point between the medial and lateral malleoli for the 2 branches of the intermediate dorsal cutaneous nerve (IDCN).ResultsReference values (mean±SD) of the onset/ peak latency (ms)/ sensory action potential amplitude (µV) for the two branches of the MDCN and for the first branch of the IDCN were 2.2±0.3/2.9±0.3/9.2±3.1, 2.2±0.3/2.8±0.3/9.1±3.0 and 2.3±0.4/2.9±0.3/8.5±2.8, respectively. For the second IDCN branch, the reference values were 2.3±0.4/3.0±0.4/7.1±2.6 but anomalous sural innervation was also found. Three types of IDCN innervations to the fourth interdigital web space were detected. In type I, the fourth interdigital webspace was innervated solely by the IDCN, whereas in type II, it was innervated by both the IDCN and distal sural nerve. In type III, it was solely innervated by the distal sural nerve.ConclusionThe results of this study show the reference values of the distal sensory branches of the superficial peroneal nerve, and provide information on the variant innervations to the fourth interdigital web space.

Variations of the superficial peroneal nerve and its terminal branches in the turkish newborn fetuses

The topography of the superficial peroneal nerve (SPN) and its terminal branches were studied, with the aim of providing further anatomical details for leg and foot in the Turkish newborn fetuses. Limbs from twenty newborn cadavers were dissected. The course of the SPN on the leg and its terminal branches on the foot were investigated. The SPN was lateral (75%), anterior (15%), or branched in both areas (10%) of the cases. The SPN in the dorsum of the feet branched further into medial dorsal cutaneous nerve (MDCn) and intermediate dorsal cutaneous nerve (IDCn). In 82.5% of the cases the MDCn and the IDCn split into three and two branches, respectively. In 10% of the cases, the MDCn gave off three, and the IDCn one terminal branches. In 7.5% of the cases, the MDCn had three while the IDCn had two branches that communicated with the lateral dorsal cutaneous nerve. The course of SPN on the anterolateral surface of the leg and its terminal branches on the dorsal surface of the foot were quite different. This unusual variant location will enable the surgeon to find and preserve the SPN and its terminal branches.

Anterior Transposition of the Superficial Peroneal Nerve Branch During the Internal Fixation of the Lateral Malleolus

Because of the anatomic variations of the superficial peroneal nerve (SPN), it has long been stressed that caution should be exercised at the time of open reduction and internal fixation (ORIF) of the lateral malleolus. Blair and Botte described type B intermediate dorsal cutaneous nerve (IDCN) in which the SPN penetrates crural fascia posterior to the fibula about 5 cm proximal to the joint and crosses the lateral border of the fibulae. We hypothesized that the type B IDCN is especially vulnerable to direct surgical injury if present and the anterior transposition of this nerve may decrease the incidence of symptoms related to the SPN injury. Fifty-three ankle fractures in 53 adult patients treated by the ORIF of lateral malleolus using the lateral approach between the periods from May 2001 to December 2006 were included. Intraoperative documentation about the presence of the type B IDCN variant at the surgical field was performed, and preoperative and postoperative sensory changes were carefully evaluated. We encountered Blair type B variant in 7 cases (12%). The IDCN was carefully dissected and transposed anteriorly before the plating. One of these seven patients had sensory deficit preoperatively, and it was recovered spontaneously 5 months after operation. There was one patient whose IDCN was inadvertently severed, and it was repaired. At the time of last follow-up, only partial recovery of the sensory deficit was noted. Five of seven patients did not show any neurologic deficit with anterior transposition. Recognition and anterior transposition of the type B IDCN could reduce the incidence of the SPN nerve injuries during the ORIF of the lateral malleolar fractures.