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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 3  |  Issue : 1  |  Page : 38-40

Common peroneal nerve entrapment during closed reduction and percutaneous pinning of paediatric distal femur fracture: Surgeons be aware!


Department of Hand Surgery, Dr. Paul Brand Centre for Hand Surgery and Peripheral Nerve Surgery, Christian Medical College and Hospital, Vellore, Tamil Nadu, India

Date of Web Publication17-Feb-2017

Correspondence Address:
Binu P Thomas
Dr. Paul Brand Centre for Hand Surgery and Peripheral Nerve Surgery, Christian Medical College and Hospital, Vellore - 632 004, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2249-9008.200290

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  Abstract 

Distal femoral metaphyseal fracture is a common injury faced by paediatric orthopaedic surgeons. This injury is usually managed with closed reduction and percutaneous Kirschner wire fixation. We present an unusual case wherein the common peroneal nerve was completely severed and entrapped in the fracture site following closed reduction and percutaneous Kirschner wire fixation of a distal femoral metaphyseal fracture.

Keywords: Distal femur fracture, foot drop, nerve entrapment


How to cite this article:
Sasi K, Thomas BP. Common peroneal nerve entrapment during closed reduction and percutaneous pinning of paediatric distal femur fracture: Surgeons be aware!. Paediatr Orthop Relat Sci 2017;3:38-40

How to cite this URL:
Sasi K, Thomas BP. Common peroneal nerve entrapment during closed reduction and percutaneous pinning of paediatric distal femur fracture: Surgeons be aware!. Paediatr Orthop Relat Sci [serial online] 2017 [cited 2019 Dec 13];3:38-40. Available from: http://www.pors.co.in/text.asp?2017/3/1/38/200290


  Introduction Top


Femur fractures are the tenth most common fracture in children[1] accounting for about 0.89% of all fractures.[2] These fractures have an incidence of 0.18 per 1000 children among boys of the 5–9 age group.[2] Fractures of the distal metaphysis of femur have been commonly treated by closed reduction and crossed Kirschner wire fixation. Nerve injuries during this procedure have been sparsely reported in available English literature. We report an unusual case of common peroneal nerve entrapment in the fracture site during closed reduction and Kirschner wire fixation of a closed distal metaphyseal fracture of femur.


  Case Report Top


A 9-year-old boy presented with left foot drop following a surgery 3 months ago. He had sustained a closed distal metaphyseal femur fracture following a fall from a bicycle 3 months ago [Figure 1]. At a local hospital, he underwent closed reduction and crossed Kirschner wire fixation followed by a plaster cast for 2 months [Figure 2] after which, the cast and Kirschner wires were removed. He was then noted to have inability to dorsiflex his left foot and difficulty clearing the ground while walking. On examination, he was found to have complete paralysis of the left common peroneal nerve and partial paralysis of tibial nerve with weak flexor hallucis longus, flexor digitorum longus, peronei, and gastrosoleus. There were no scars or sinuses. Electrophysiological studies revealed left tibial and peroneal neuropathy with absent compound muscle action potentials and reduced sensory nerve action potentials. A plain radiograph revealed united fracture of the distal femoral metaphysis [Figure 3]. In view of short duration and closed nature of the injury and the surgery, it was decided to observe and follow up the patient. Thereafter, the patient was reviewed at 14 months following trauma; a clinical evaluation revealed a persistent complete paralysis of the common peroneal nerve but partial recovery of the tibial nerve with persistent weakness of the peronei muscles. Electrophysiological studies revealed some reinnervation of the tibial nerve but only denervation of the common peroneal nerve. He underwent surgical exploration [Figure 4]. It was found that the common peroneal nerve was completely severed with a proximal stump neuroma and the distal end was completely ensnared at the site of fracture union and entrapped by the fracture callus [Figure 5]. The tibial nerve was tethered and constricted by the fibrous tissue around the callus. He underwent microsurgical group fascicular grafting of the common peroneal nerve with sural nerve graft and neurolysis of the tibial nerve [Figure 6]. At 5-month follow-up, he showed some evidence of recovery with a medical research council (MRC) grade 2 power in the tibialis anterior muscle.
Figure 1: Preoperative radiograph showing extension-type distal femoral metaphyseal fracture

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Figure 2: Postoperative radiograph post-Kirschner wire fixation

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Figure 3: Follow-up radiograph showing fracture union

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Figure 4: Exploration of sciatic, common peroneal and tibial nerves

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Figure 5: Intraoperative findings

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Figure 6: Sural nerve grafting of common peroneal nerve

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  Discussion Top


Closed fracture of the distal femoral metaphysis is an injury that most paediatric orthopaedic surgeons will be called in to treat.[1],[2] Injuries to the distal femur are almost twice as common as the proximal tibial injuries.[3] One of the most common patterns is the hyperextension injury that is associated with a high risk of neurovascular injuries.[3] Closed reduction and percutaneous Kirschner wire fixation has been shown to give the best results for such injuries.[4] Closed reduction is fraught with risks as gastrocnemius insertion to the distal femur causes the distal fragment to angulate posteriorly.[5] Other methods of fixation used are percutaneous screws or Steinmann pins.[3] The most common causes of sciatic neuropathy in children are traumatic and iatrogenic[6] but reports of such injuries are sparse. In their classic article, Clawson and Seddon[7] stated that the results of a repair or grafting of the sciatic nerve or the common peroneal nerve are just satisfactory. This case is of significance as every paediatric orthopaedic surgeon who treats this injury will face the risk of such a dreaded complication. A parallel can be drawn to the Holstein–Lewis fracture syndrome in which the radial nerve is entrapped in the distal shaft of humerus fracture closely related to manipulative reduction.[8] Awareness of the potential risk of such severe neurological damage associated with closed reduction and percutaneous pinning of distal femoral metaphysis will aid the surgeon in avoiding the same. In the unfortunate event of such a complication, close follow-up with nerve conduction studies and exploration and neurolysis or grafting is the best management.[9]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Cooper C, Dennison EM, Leufkens HG, Bishop N, van Staa TP. Epidemiology of childhood fractures in Britain: A study using the general practice research database. J Bone Miner Res 2004;19:1976-81.  Back to cited text no. 1
    
2.
Lyons RA, Delahunty AM, Kraus D, Heaven M, McCabe M, Allen H et al. Children’s fractures: A population based study. Inj Prevent 1999;5:129-32.  Back to cited text no. 2
    
3.
Flynn JM, Skaggs D, Sponseller PD, Ganley TD, Kay RM, Leitch KK. The operative management of pediatric fractures of the lower extremity. J Bone Joint Surg Am 2002;84:2288-300.  Back to cited text no. 3
    
4.
Thomson JD, Stricker SJ, Williams MM. Fractures of the distal femoral epiphyseal plate. J Pediatr Orthop 1995;15:474-8.  Back to cited text no. 4
    
5.
Canale TS, Tolo VT. Fractures of the femur in children. Instr Course Lect 1995;44:255-73.  Back to cited text no. 5
    
6.
Srinivasan J, Ryan MM, Escolar DM, Darras B, Jones HR. Pediatric sciatic neuropathies: A 30-year prospective study. Neurology 2011;76:976-80.  Back to cited text no. 6
    
7.
Clawson DK, Seddon HJ. The results of repair of the sciatic nerve. J Bone Joint Surg Br 1960;42-B:205-12.  Back to cited text no. 7
    
8.
Holstein A, Lewis GB. Fractures of the humerus with radial-nerve paralysis. J Bone Joint Surg Am 1963;45:1382-8.  Back to cited text no. 8
    
9.
Kim DH, Murovic JA, Tiel R, Kline DG. Management and outcomes in 353 surgically treated sciatic nerve lesions. J Neurosurg 2004;101:8-17.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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