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Re: Отсутствие активного разгибания I пальца стопы
Alexander Artemiev 13 Февраль 2003, 01:50
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Мне довелось однажды задеть спицей малоберцовый нерв при эстетической коррекции голени... Два месяца, которые прошли до начала восстановления - самые грустные в моей жизни...Перечитал,
пересоветовался, пережил...
Итак:
1.Независимо от уровня повреждения периферических нервов - начиная от сдавления грыжей на поясничном уровне - в первую очередь страдает порция малоберцового нерва.
2. Из этой порции нерв,иннервирующий м.extensor hallucis longus - самый страдающий - эта мышца и у меня восстановилась в последнюю очередь.
3. Во всех учебниках анатомии дифференциация этих нервов заканчивается на уровне разделения общего малоберцового нерва на глубокую и поверхностную ветвь.
И я до определенного времени был уверен, что мелкие ветви входят в мышцу как бы в проксимальной части брюшка. Онако мне доводилось
повреждать именно нерв, иннервирующий эту мышцу почти в средней трети голени,или, скажем, на границе верхней и средней трети... Видимо,
нерв входит в мышцу где-то в середине брюшка...
4. Я эти случаи как-то во всех случаях связывал со спицами - может быть,не совсем внимательно смотрел до операции...
С уважением Александр Артемьев
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Re: Отсутствие активного разгибания I пальца стопы
Отправитель: Alexander Chelnokov 13 Февраль 2003, 02:06
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a> Мне довелось однажды задеть спицей малоберцовый нерв при эстетической
a> коррекции голени... Два месяца, которые прошли до начала
Повезло, что нетяжелое повреждение было.
a> мышцу как бы в проксимальной части брюшка. Онако мне доводилось
a> повреждать именно нерв, иннервирующий эту мышцу почти в средней трети
Да, именно такое встречалось. Непонятна избирательность у пациента с переломом вертлужной впадины.
Вот что успел в Medline накопать:
===============================================
Knee Surg Sports Traumatol Arthrosc 1999;7(1):15-9 Related Articles, Links
Nerve and vessel injuries during high tibial osteotomy combined with
distal fibular osteotomy: a clinically relevant anatomic study.
Georgoulis AD, Makris CA, Papageorgiou CD, Moebius UG, Xenakis T,
Soucacos PN.
Department of Orthopaedic Surgery, University of Ioannina Medical
School, Greece.
Based on our clinical experience and an anatomical study, we examined the conditions under which injury to the popliteal artery, tibial nerve or peroneal nerve and its branches may occur during high tibial osteotomy. In 250 high tibial osteotomies performed in our department, we observed the following intraoperative complications. (1) The popliteal artery was severed in 1 patient and repaired by the same surgical team using a microsurgical technique. (2) A tibial nerve paresis also occurred in 1 patient. (3) In 3 patients, temporary palsy of the anterior tibialis muscle was documented. (4) In 4 other patients, palsy of the extensor hallucis longus occurred. To
investigate the causes of these complications in the popliteal artery, tibial nerve and branches of the peroneal nerve, we dissected the neurovascular structures surrounding the area of the osteotomy in 10 cadaveric knees and performed a high tibial osteotomy in another 13 cadaveric knees. We concluded the following. (1) The popliteal artery and tibial nerve are protected, at the level of the osteotomy, behind the popliteus and tibialis posterior muscles. Damage can occur only by placing the Hohman retractor behind the muscles. The insertion of the muscles is very close to the periosteum and can be separated only with a scalpel. (2) The tibialis anterior muscle is innervated by a group
of branches arising from the deep branch of the peroneal nerve. In two-thirds of the dissected knees, we found a main branch close to the periosteum, which can be damaged by dividing the muscle improperly or due to improper placement and pressure of the Hohman retractor. This
may explain the partially reversible muscle palsy. (3) The extensor hallucis longus is also innervated by 2-3 thin branches, arising from
the deep branch of the peroneal nerve, but in 25% of the specimens, only one large branch was found. This branch is placed under tension
by manipulating the distal tibia forward. Thus, it may be damaged by the Hohman retractor during distal screw fixation, tensioned by hyperextension or directly injured during midshaft fibular osteotomy.
DP - 1979 Feb
TI - [The isolated loss of extension of the great toe following osteotomy of
the fibula (author's transl)]
PG - 31-8
AB - A peroneal nerve palsy can be observed following operative procedures or
traumatic lesions of the lower leg. Primary damage of the nerve must be
differentiated from the tibialis-anterior syndrome and the
pseudo-paralysis. Following corrective osteotomies of the tibia with
dissection of the fibula in the upper or medial third isolated lesions of
the extensor hallucis longus muscle can be seen. Electromyographic and
anatomical studies reveal that they may be caused by an isolated damage of
the motor nerve fibres connecting the deep branch of the peroneal nerve
with the extensor hallucis longus muscle lying very close to the fibula.
Suggestions how to avoid this damage are made in the paper.
FAU - Sturz, H
AU - Sturz H
FAU - Rosemeyer, B
AU - Rosemeyer B
LA - ger
PT - Journal Article
TT - Die isolierte Grosszehenheberschwache nach Fibulaosteotomie.
CY - GERMANY, WEST
TA - Z Orthop Ihre Grenzgeb
JID - 1256465
SB - IM
MH - Electromyography
MH - English Abstract
MH - Female
MH - Hallux/*innervation
MH - Human
MH - Male
MH - Osteotomy/*adverse effects
MH - Paralysis/*etiology/physiopathology
MH - *Peroneal Nerve/anatomy & histology/injuries
MH - Tibia/*surgery
EDAT- 1979/02/01
MHDA- 1979/02/01 00:01
PST - ppublish
SO - Z Orthop Ihre Grenzgeb 1979 Feb;117(1):31-8.
DP - 1992 Mar
TI - The dropped big toe.
PG - 222-5
AB - Surgical procedures for exposure of the upper third of the fibula have
been known to cause weakness of the long extensor of the big toe
post-operatively. The authors present three representative cases of
surgically induced dropped big toe. From cadaveric dissection, an anatomic
basis was found for this phenomenon. The tibialis anterior and extensor
digitorum longus muscles have their origin at the proximal end of the leg
and receive their first motor innervation from a branch that arises from
the common peroneal or deep peroneal nerve at about the level of the neck
of the fibula. However, the extensor hallucis longus muscle originates in
the middle one-third of the leg and the nerves innervating this muscle run
a long course in close proximity to the fibula for up to ten centimeters
from a level below the neck of the fibula before entering the muscle.
Surgical intervention in the proximal one-third of the fibula just distal
to the origin of the first motor branch to the tibialis anterior and
extensor digitorum longus muscles carries a risk of injury to the nerves
innervating the extensor hallucis longus.
AD - Department of Orthopaedic Surgery, National University of Singapore.
FAU - Satku, K
AU - Satku K
FAU - Wee, J T
AU - Wee JT
FAU - Kumar, V P
AU - Kumar VP
FAU - Ong, B
AU - Ong B
FAU - Pho, R W
AU - Pho RW
LA - eng
PT - Journal Article
CY - SINGAPORE
TA - Ann Acad Med Singapore
JID - 7503289
SB - IM
MH - Adolescent
MH - Case Report
MH - Female
MH - Foot Deformities, Acquired/*etiology/pathology/radiography
MH - *Hallux
MH - Human
MH - Intraoperative Complications/*etiology/pathology/radiography
MH - Middle Age
MH - Peroneal Nerve/*injuries
EDAT- 1992/03/01
MHDA- 1992/03/01 00:01
PST - ppublish
SO - Ann Acad Med Singapore 1992 Mar;21(2):222-5.
DP - 1999 May
TI - Dropped hallux after the intramedullary nailing of tibial fractures.
PG - 481-4
AB - We made a prospective study of 208 patients with tibial fractures treated
by reamed intramedullary nailing. Of these, 11 (5.3%) developed
dysfunction of the peroneal nerve with no evidence of a compartment
syndrome. The patients with this complication were significantly younger
(mean age 25.6 years) and most had closed fractures of the forced-varus
type with relatively minor soft-tissue damage. The fibula was intact in
three, fractured in the distal or middle third in seven, with only one
fracture in the proximal third. Eight of the 11 patients showed a 'dropped
hallux' syndrome, with weakness of extensor hallucis longus and numbness
in the first web space, but no clinical involvement of extensor digitorum
longus or tibialis anterior. This was confirmed by nerve-conduction
studies in three of the eight patients. There was good recovery of muscle
function within three to four months in all cases, but after one year
three patients still had some residual tightness of extensor hallucis
longus, and two some numbness in the first web space. No patient required
further treatment.
AD - Edinburgh Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh, UK.
FAU - Robinson, C M
AU - Robinson CM
FAU - O'Donnell, J
AU - O'Donnell J
FAU - Will, E
AU - Will E
FAU - Keating, J F
AU - Keating JF
LA - eng
PT - Journal Article
CY - ENGLAND
TA - J Bone Joint Surg Br
JID - 0375355
SB - AIM
SB - IM
MH - Adolescent
MH - Adult
MH - Aged
MH - Female
MH - Follow-Up Studies
MH - *Fracture Fixation, Intramedullary
MH - Hallux/*innervation
MH - Human
MH - Hypesthesia/etiology
MH - Male
MH - Middle Age
MH - Muscle Denervation
MH - Muscle, Skeletal/innervation
MH - Peroneal Nerve/*injuries
MH - Postoperative Complications/*etiology
MH - Tibial Fractures/*surgery
EDAT- 2000/06/29 11:00
MHDA- 2000/07/15 11:00
PST - ppublish
SO - J Bone Joint Surg Br 1999 May;81(3):481-4
DP - 1991
TI - Complications of reamed intramedullary nailing of the tibia.
PG - 184-9
AB - A retrospective review of 60 acute fractures of the tibia treated with
reamed intramedullary nailing was undertaken to document the spectrum of
complications associated with this procedure. Forty-five tibial fractures
were followed to radiographic union; follow-up averaged 25 months (range,
10-63 months). Complications were categorized into intraoperative, early
postoperative, and late postoperative groups. Intraoperative complications
occurred in 6 of the 60 (10%) fractures and included propagation of the
tibial fracture into the insertion site of the nail in four cases. In each
of two other fractures, at least one of the proximal interlocking screws
was documented to have poor bony purchase. These complications did not
affect final fracture alignment or clinical result. Early complications
included soft-tissue complications, complications of fixation, and
neurologic complications. Four patients developed hematomas at the nail
insertion site. Eight fractures were stabilized in greater than 5 degrees
of varus or valgus. Neurologic deficits directly related to the procedure
were documented in 18 patients (30%). The majority were minor sensory
neuropraxias of the peroneal nerve. Sixteen (89%) of these nerve palsies
were transient, resolving within 3-6 months. Two patients had persistent
nerve deficits at 1-year follow-up. In the late complications group, 10 of
the 45 (22%) tibial fractures followed to union developed patellar
tendinitis. Nonunion developed in two fractures, both of which required
additional surgical procedures to obtain fracture union. Two deep
infections occurred, both of which resolved after local wound care,
fracture union, and nail removal. Overall, 26 of the 45 tibial fractures
available for follow-up (58%) developed some complication attributable to
the procedure.(ABSTRACT TRUNCATED AT 250 WORDS)
AD - Department of Orthopaedics, Hospital for Joint Diseases, New York, New
York.
FAU - Koval, K J
AU - Koval KJ
FAU - Clapper, M F
AU - Clapper MF
FAU - Brumback, R J
AU - Brumback RJ
FAU - Ellison, P S Jr
AU - Ellison PS Jr
FAU - Poka, A
AU - Poka A
FAU - Bathon, G H
AU - Bathon GH
FAU - Burgess, A R
AU - Burgess AR
LA - eng
PT - Journal Article
CY - UNITED STATES
TA - J Orthop Trauma
JID - 8807705
SB - IM
MH - Adolescent
MH - Adult
MH - Bone Nails
MH - Female
MH - Follow-Up Studies
MH - Fracture Fixation, Intramedullary/*adverse effects
MH - Hematoma/etiology
MH - Human
MH - Infection/etiology
MH - Intraoperative Complications
MH - Male
MH - Middle Age
MH - Peripheral Nervous System Diseases/etiology
MH - Peroneal Nerve
MH - Postoperative Complications
MH - Retrospective Studies
MH - Tibial Fractures/*surgery
EDAT- 1991/01/11 19:15
MHDA- 2001/03/28 10:01
PST - ppublish
SO - J Orthop Trauma 1991;5(2):184-9
DP - 2002 May
TI - Extensor hallucis longus innervation: an anatomic study.
PG - 245-51
AB - Thirty legs from skeletally mature embalmed cadavers were dissected to
define the most common pattern and the variants of innervation of the
extensor hallucis longus muscle and its clinical significance.
Twenty-seven muscles had only one innervating branch (90%). Only three
muscles had two innervating branches (10%). Twenty-one of the branches
entered the muscles from the fibular side (63.6%), six entered the muscles
from the tibial side (18.2%), and six entered the muscles from the
anterior edge (18.2%). The branches innervating the extensor hallucis
longus from the fibular side had a closer relation with the fibular
periosteum than those entering the muscle from the tibial side or the
anterior edge. The mean length of these branches between their points of
origin and entry in the extensor hallucis longus was 5.0 +/- 1.5 cm. The
high risk zone for the iatrogenic injury to the muscular branch of the
extensor hallucis longus was located between 5.9 +/- 1.7 and 10.9 +/- 1.7
cm inferior to the most distal palpable point of the fibular head. The
current study confirmed that the extensor hallucis longus was supplied
mostly by one nerve that usually entered the muscle from the fibular side
and had a close relation to the fibular periosteum in the dangerous zone.
AD - Department of Orthopaedic Surgery, Medical College of Ohio, Toledo, OH
43614-5807, USA.
FAU - Elgafy, Hossein
AU - Elgafy H
FAU - Ebraheim, Nabil A
AU - Ebraheim NA
FAU - Shaheen, Philip E
AU - Shaheen PE
FAU - Yeasting, Richard A
AU - Yeasting RA
LA - eng
PT - Journal Article
CY - United States
TA - Clin Orthop
JID - 0075674
SB - AIM
SB - IM
MH - Cadaver
MH - Dissection
MH - Female
MH - Human
MH - Leg/*innervation
MH - Male
MH - Muscle, Skeletal/*innervation
EDAT- 2002/04/20 10:00
MHDA- 2002/06/12 10:01
PST - ppublish
SO - Clin Orthop 2002 May;(398):245-51
========================================================================
--
Best regards,
Alexander N. Chelnokov
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Re: Отсутствие активного разгибания I пальца стопы
DG Alllan 13 Февраль 2003, 01:51
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The nerve to the EHL is a proximal branch off the peroneal. It can run along the fibula in its proximal third. It is danger especially during osteotomies of the fibula, therefore the fibula problably should not be cut in its
proximal third.
DG Alllan
Springfield Illinois, USA
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Re: Отсутствие активного разгибания I пальца стопы
Chris Oliver 13 Февраль 2003, 01:53
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J Bone Joint Surg Br 1999 May;81(3):481-4
Dropped hallux after the intramedullary nailing of tibial fractures.
Robinson CM, O'Donnell J, Will E, Keating JF.
Edinburgh Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh, UK.
We made a prospective study of 208 patients with tibial fractures treated by reamed intramedullary nailing. Of these, 11 (5.3%) developed dysfunction of the peroneal nerve with no evidence of a compartment syndrome. The patients with this complication were significantly younger (mean age 25.6 years) and most had closed fractures of the forced-varus type with relatively minor soft-tissue damage. The fibula was intact in three, fractured in the distal or middle third in seven, with only one fracture in the proximal third. Eight of the 11
patients showed a 'dropped hallux' syndrome, with weakness of extensor hallucis longus and numbness in the first web space, but no clinical involvement of extensor digitorum longus or tibialis anterior. This was confirmed by nerve-
conduction studies in three of the eight patients. There was good recovery of muscle function within three to four months in all cases, but after one year three patients still had some residual tightness of extensor hallucis longus, and two some numbness in the first web space. No patient required further treatment.
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Re: Отсутствие активного разгибания I пальца стопы
David Goetz 14 Февраль 2003, 09:10
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It is possible to damage the motor branch to the EHL with the drill bit for the proximal locking screw of the tibial rod. We have had one such case confirmed: loss of isolated motor loss to the EHL without other weakness or numbness. A brief contracture of the EHL was seen intraoperative at the time of the drill "plunge" into the anterior compartment.
David R. Goetz MD
Medical Director, Orthopaedic Trauma
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Re: Отсутствие активного разгибания I пальца стопы
Michael Tucker 14 Февраль 2003, 09:12
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The circumstance of 'dropped hallux' does occur occasionally after tibial IM nailing. I have experienced this 2-3 times in my career without obvious explanation. This subject was covered reasonably well in the following article
JBJS (British) 81(3):481-484 Dropped Hallux After Intramedullary Nailing of Tibial Fractures
Should be available online. Hope this helps.
Mike Tucker
Michael C. Tucker, MD
Director, Orthopaedic Trauma Service
Assistant Professor of Orthopaedic Surgery
Department of Orthopaedic Surgery
Medical College of Georgia
1120 15th St.
Augusta, GA 30912
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Отсутствие активного разгибания I пальца стопы
