Department of Neurosurgery, University of Wisconsin, Madison, WI, USA
19.1 Case Presentation
A 37-year-old male presents with an 8-month history of a left foot drop . This started immediately after an accident where a piece of glass lacerated the anterolateral aspect of the left upper leg. He was seen in a local emergency room, where the wound was washed out and the skin was closed, with a report of injured nerves and muscles, but no attempt was made to repair them. Since then he has had a left foot drop and 6/10 pain on the VAS . He underwent PT with no improvement. He is wearing a brace. PMH significant for hypertension, DVT, pulmonary embolism, and hernia repairs. FH positive for diabetes in the father and colon cancer in the mother. On examination, TA 0, EHL 0, extensor digitorum 0, eversion 0, the remaining muscle groups are 5/5. There is no sensation in the outer leg below the laceration or the dorsum of the foot. He has a Tinel’s sign over the previous scar .
What is the diagnosis?
What studies do you need?
What do you recommend?
Describe the treatment.
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Laceration scar in the left anterolateral leg (Fig. 19.1). In the setting of a foot drop, this probably lacerated the peroneal n involving both superficial (inability to evert) and deep branches (inability to dorsiflex).
EMG / NCS : Left peroneal neuropathy, axonal, severe, distal to the branch to the short head of biceps femoris (this is the last muscle supplied by the peroneal division in the thigh). Image the area of injury with either US or MRI to assess for nerve continuity and neuroma formation. US revealed transection of both superficial and deep peroneal nn distal to the common peroneal bifurcation, about 2 cm distal to the fibular head.
Surgical exploration and repair . The goals of surgery are functional recovery and pain control. Low odds should be provided for functional recovery since it has been more than 8 months from the injury , and because the peroneal n in general doesn’t recover very well . This is a sharp laceration (neurotmesis). It should have been repaired immediately (appendix 1). The late presentation does not preclude surgical management.
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