1/20. Salvage of open tibial fracture with segmental loss of tibial nerve: case report and review of the literature.We report a case history, treatment, and follow-up of an open comminuted distal tibial fracture with significant soft tissue loss and segmental loss of the tibial nerve and posterior tibial artery. This constellation of injuries with an insensate plantar foot has often been an indication for amputation. In this instance, a functional distal extremity was salvaged with the use of Ilizarov fixation, delayed primary tibial nerve cable grafting, and staged soft tissue coverage. Clinical follow-up and review of the literature on the techniques used are offered for consideration.- - - - - - - - - - ranking = 1keywords = nerve (Clic here for more details about this article) |
2/20. Displacement of the common peroneal nerve associated with upper tibial fracture: implications for fine wire fixation.The constant anatomic position of the common peroneal nerve is relied on when performing fine wire external fixation in the upper tibia. We report the case of a sixty-two-year-old woman with a Schatzker Type V fracture of her right tibial plateau and upper-third diaphyseal fracture associated with displacement and shortening of the upper tibia. She was treated by minimal internal fixation of the intraarticular fracture and application of a Sheffield Hybrid External Fixator. During percutaneous insertion of the reference wire in the fibular head, a distal muscle twitch alerted the surgeon, and the common peroneal nerve was duly explored and found displaced forward over the fibular head, dangerously close to the wire. It is postulated that at the time of injury, the common peroneal nerve was displaced anteriorly and that despite reduction of the tibial fractures, it had failed to return to its original position.The mechanism of this was confirmed by an anatomic study on an above-the-knee amputation specimen in which the metaphyseal-diaphyseal element of the fracture was reproduced. We recommend insertion of the reference fibular wire with the knee in flexion. Open insertion of this wire, with an incision down to bone and exposure of the fibular head, is recommended in cases in which severe trauma with shortening of the upper tibia, with possible disruption of the tibiofibular joint, puts the nerve in danger of injury.- - - - - - - - - - ranking = 1.3333333333333keywords = nerve (Clic here for more details about this article) |
3/20. Unimuscular neuromuscular insult of the leg in partial anterior compartment syndrome in a patient with combined fractures.A complicated case of ipsilateral fractures of the left femur and tibia after a road traffic accident is reported. The patient presented with numbness of the first web of his left foot and contracture of the extensor hallucis longus muscle, with fixed length deformity after intramedullary nailing of the femur and tibia. The extensor digitorum longus and tibialis anterior muscles were spared. Tinel's sign could be elicited at the mid-portion of the anterior compartment of the injured leg. This indicated that the distal half of the anterior tibial nerve (deep peroneal nerve), together with the extensor hallucis muscle of the anterior compartment of the leg, had been damaged. The subsequent management of this patient is described.- - - - - - - - - - ranking = 0.33333333333333keywords = nerve (Clic here for more details about this article) |
4/20. Single-stage achilles tendon reconstruction using a composite sensate free flap of dorsalis pedis and tendon strips of the extensor digitorum longus in a complex wound.The reconstruction of the posterior heel including a wide defect of the Achilles tendon is difficult as a result of complicated infection, deficient soft tissue for coverage, and functional aspects and defects of the tendon itself. As a single-stage procedure, various methods of tendon transfer and tendon graft have been reported along with details of local flaps or island flaps for coverage. With advances in microsurgical techniques and subsequent refinements, several free composite flaps, including tendon, fascia, or nerve, have been used to reconstruct large defects in this area without further damaging the traumatized leg. The authors report such a single-stage reconstruction of a composite achilles tendon defect using the extensor digitorum longus tendon of the second to fourth toe in combination with a dorsalis pedis flap innervated by the superficial peroneal nerve. The follow-up of this case has proved a satisfactory outcome to date.- - - - - - - - - - ranking = 0.33333333333333keywords = nerve (Clic here for more details about this article) |
5/20. Composite vascularised osteocutaneous fibula and sural nerve graft for severe open tibial fracture--functional outcome at one year: a case report.Management of severe open tibial fracture with neurovascular injury is difficult and controversial. Primary amputation is an acceptable option as salvaging the injured, insensate, and ischaemic limb may result in chronic osteomyelitis and non-functional limb. We report a case of open tibial fracture associated with segmental bone and soft tissue loss, posterior tibial nerve and artery injuries, which was further complicated by chronic osteo-myelitis treated with composite vascularised osteocutaneous fibula and sural nerve graft. Functional outcome of the injured limb at one-year follow-up was satisfactory: the patient was capable of achieving full weightbearing and was able to appreciate crude touch, pain, proprioception, and temperature at the plantar aspect of the foot. There was no pressure sore or ulceration.- - - - - - - - - - ranking = 1keywords = nerve (Clic here for more details about this article) |
6/20. Ultrasound guidance for a lateral approach to the sciatic nerve in the popliteal fossa.Descriptions of the use of ultrasound for nerve location have focused on upper limb blocks. We present a case in which ultrasound imaging was used for a lateral approach to the sciatic nerve in the popliteal fossa. Ultrasound images taken proximal to the popliteal crease showed tibial and common peroneal nerves as round hyperechoic structures superficial and lateral to the tibial artery. Under direct ultrasound guidance, we placed a block needle close to the tibial nerve and confirmed its position with nerve stimulation. Injected local anaesthetic was seen on ultrasound as it spread around both tibial and common peroneal nerves.- - - - - - - - - - ranking = 1.6666666666667keywords = nerve (Clic here for more details about this article) |
7/20. Use of the extended-pedicle vastus lateralis free flap for lower extremity reconstruction.BACKGROUND: Soft-tissue coverage in the lower extremity usually requires a flap with a long pedicle, low donor-site morbidity, and versatility in terms of shape and volume. The extended-pedicle free vastus lateralis muscle flap has previously been described for head and neck cancer, and it fulfills these requirements. methods: Twelve patients with lower extremity defects underwent reconstruction with an ipsilateral free vastus lateralis muscle flap. The flap included a segment of the distalmost part of the muscle, distal to the entry point of the motor nerve to the vastus lateralis, based on the descending branch of the lateral femoral circumflex vessels. Up to 20 cm of vascular pedicle with a large caliber was obtained. In three cases, a combined distal vastus lateralis and anterolateral thigh flap was used as a chimeric flap. RESULTS: All flaps were successful. infection developed in two cases and required flap reelevation and new wound debridement. There was no substantial subjective donor-site morbidity. CONCLUSIONS: Elevation of the flap can be performed with the patient in the supine position and is extremely fast and straightforward, without the added difficulty of anatomical variation or extensive intramuscular vascular dissection. The pedicle is long and of large caliber. Although the series is short, the authors conclude that this is a useful free flap for lower extremity reconstruction.- - - - - - - - - - ranking = 0.16666666666667keywords = nerve (Clic here for more details about this article) |
8/20. 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.- - - - - - - - - - ranking = 1.5keywords = nerve (Clic here for more details about this article) |
9/20. Extensor mechanism disruption after contralateral middle third patellar tendon harvest for anterior cruciate ligament revision reconstruction.The contralateral central third patellar tendon autograft is a reliable graft choice for revision, and recently, for primary reconstruction of the anterior cruciate ligament (ACL). We report 2 complications including a lateral third tibial tuberosity fracture and a distal patellar tendon avulsion with contralateral patellar tendon autograft with disruption of the extensor mechanism of the donor knee. A patient sustained a lateral tibial tuberosity fracture of the donor knee and underwent open reduction and internal fixation. At 1-year follow-up, she had no extensor lag and full range of motion. Another patient sustained a distal patellar tendon avulsion of the donor knee and underwent primary repair. Three years postoperatively, she had a full range of motion and no extensor lag. Although contralateral middle third patellar tendon autograft for primary and revision ACL reconstruction is established in the literature, extensor mechanism complications can occur. Technical considerations are important to avoid weakening the remaining patellar tendon insertion. Postoperative nerve blocks or local anesthetics may alter pain feedback for regulation of weight bearing and contribute to overload of the donor knee.- - - - - - - - - - ranking = 0.16666666666667keywords = nerve (Clic here for more details about this article) |
10/20. [Primary Ilizarov ankle fusion for nonreconstructable tibial plafond fractures]OBJECTIVE: ankle arthrodesis in a plantigrade position. In high-energy open injuries with segmental bone loss: proximal tibial metaphyseal corticotomy with distal Ilizarov bone transport for compensation of leg length discrepancy. INDICATIONS: Posttraumatic loss of the tibial plafond, usually resulting from open fracture type IIIC. CONTRAINDICATIONS: Ipsilateral foot injuries impairing ambulation after fusion. Severe injury to the posterior tibial nerve with absent plantar sensation. Soft-tissue injury not manageable surgically. Inadequate patient compliance. Advanced age. Severe osteoporosis. Acute infection. SURGICAL TECHNIQUE: Standard technique: anteromedial longitudinal incision. Removal of remaining articular cartilage. Passing of Ilizarov wires through the distal fibula, talar neck and body. Placement of 5-mm half-pins through stab incisions, perpendicular to the medial face of the tibial shaft. A lateral to medial 1.8-mm Ilizarov wire in the proximal tibial metaphysis is optional. Callus distraction/Ilizarov bone transport: exposure through an anteromedial incision or transverse traumatic wound. Removal of small residual segment of tibial plafond blocking transport. Retain small vascularized bone fragments not blocking transport. For Ilizarov external fixation, two rings in the proximal tibial region. Drill osteoclasis of the tibial metaphysis 1 cm distal to the tibial tuberosity and complete with Ilizarov osteotome. Secure the Ilizarov threaded rods or clickers. Weight bearing as tolerated. Begin distraction 14 days after corticotomy at a rate of 0.5-1 mm per day depending on patient's age. After docking: Ilizarov ankle arthrodesis. RESULTS: Between January 1993 and September 1996, four patients (two men, two women) with severe, nonreconstructable fractures of the tibial plafond were treated. Callus distraction and Ilizarov bone transport in three patients. Age range 19-68 years (average age 45.7 years). Mean follow-up 6.6 years (4 years 9 months to 7 years 4 months). Average duration of the entire treatment in external fixation 54.4 days/cm for the three bone distraction patients. Mean transport 6 cm (4.5-8.5 cm). One patient required repeat ankle arthrodesis.- - - - - - - - - - ranking = 0.16666666666667keywords = nerve (Clic here for more details about this article) |
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